IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEBRASKA

_________________________________,	)

)

Plaintiff(s),	)

)

v.	)	CASE NO. ___________________

)

_________________________________,	)

)

Defendant(s).	)

DISCLOSURE OF CORPORATE AFFILIATIONS,

FINANCIAL INTEREST, AND BUSINESS ENTITY CITIZENSHIP

Pursuant to Federal Rule of Criminal Procedure 12.4 and GMAC Commercial Credit

LLC v. Dillard Department Stores, Inc., 357 F.3d 827, 828 (8th Cir. 2004), _____________

_________________________________, makes the following disclosures concerning parent

(Party Name)

companies, subsidiaries, partners, limited liability entity members and managers, affiliates, and

similar entities, as well as unincorporated associations or similar entities.

[INSTRUCTIONS: Check the applicable box or boxes, and fill in any required information.]

This party is an individual.

This party is a publicly held corporation or other publicly held entity.

This party has parent corporations

If yes, identify all parent corporations, including grandparent and great-
grandparent corporations:

Ten percent or more of the stock of a party is owned by a publicly held corporation or other publicly held entity.

If yes, identify all such owners:

Another publicly held corporation or another publicly held entity has a direct financial interest in the outcome of the litigation.

If yes, identify all corporations or entities and the nature of their interest:

This party is a limited liability company or limited liability partnership.

If yes, identify each member of the entity and the member's state of citizenship:

This party is an unincorporated association or entity.

If yes, identify the members of the entity and their states of citizenship:

Additional information:

Date: _____________________________	_______________________________

(Signature)

CERTIFICATE OF SERVICE

I hereby certify that on _______________________, I electronically filed the foregoing with the Clerk of Court using the CM/ECF system, which will send notification of such filing to the following:

________________________________________________________________,

and I hereby certify that I have mailed by United States Postal Service the document to the following CM/ECF participants:_______________________________________________.

s/______________________________