Please fill in all the mandatory fields (marked by *)

1.
* For verification purposes only pursuant to 18 U.S.C. §§ 2256 et seq.
2.
3.
4.
* For verification purposes only pursuant to 18 U.S.C. §§ 2256 et seq.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
RATE THE CURRENT STATE OF YOUR RELATIONSHIPS (1 BEING WORST AND 5 BEING BEST).
21.






22.






23.






24.






25.






26.





27.





28.





29.
30.
 Yes    No
31.
32.
 Yes    No
33.
34.
35.
* For verification purposes only pursuant to 18 U.S.C. §§ 2256 et seq.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
ON A SCALE ON 1 TO 5 (1 IS MOST FALSE AND 5 IS MOST TRUE), PLEASE ANSWER FOR THE STATEMENTS BELOW:
67.





68.





69.





70.





71.





72.





73.





74.





75.





76.
77.
78.
79.
80.
81.