UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE
United States of America v. _________________________ ________________________ Defendant(s) _____________________ Criminal Case No.
ORGANIZATIONAL VICTIM STATEMENT LCrR 12.4 (b) [This form is to be completed and filed by the government only when the victim of alleged criminal activity is an organization.] The alleged victim in connection with the above-captioned case is the following organization:
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The government identifies the following parent corporation and any publicly held corporation that owns 10% or more of the victim's stock:
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The government identifies the following publicly held corporation with which a merger agreement with the victim exists:
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Where a partnership is a victim, the government identifies the following publicly held corporation that holds an interest in the partnership, the corporate partner's parent corporation, and any publicly held corporation that owns 10% or more of the corporate partner's stock:
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The victim has none of the above.
Respectfully submitted,
[Name of Corporation/Partnership] [Name of Corporation/Partnership]
Date:
/s/ [Name of Password Registrant] /s/ [Name of Password Registrant] [Name of Password Registrant] [Name of Password Registrant] [Bar No.] [Bar No.] [Law Firm Name] [Law Firm Name] [Address] [Address] [City, State, Zip Code] [City, State, Zip Code] [Phone: (999) 999-9999] [Phone: (xxx) xxx-xxxx] [E-mail: [email protected]] [E-mail: [email protected]]
CERTIFICATE OF SERVICE I hereby certify that this Disclosure Statement was served on the following persons on this date and in the manner specified herein: Electronically Served Through ECF: [Names of Filing Users]
Conventionally Served: [Name and Address of Non-Filing Users].
Date:
/s/ [Name of Password Registrant] /s/ [Name of Password Registrant] [Name of Password Registrant] [Name of Password Registrant] [Bar No.] [Bar No.] [Law Firm Name] [Law Firm Name] [Address] [Address] [City, State, Zip Code] [City, State, Zip Code] [Phone: (999) 999-9999] [Phone: (xxx) xxx-xxxx] [E-mail: [email protected]] [E-mail: [email protected]]