Rule text
IN THE COURT OF COMMON PLEAS ______________________________ DIVISION ______________________________ COUNTY, OHIO Case No. Plaintiff/Petitioner 1 Judge vs./and Magistrate Defendant/Petitioner 2 Instructions: Check local court rules to determine when this form must be filed. List ALL OF YOUR PROPERTY AND DEBTS, THE PROPERTY AND DEBTS OF YOUR SPOUSE, AND ANY JOINT PROPERTY OR DEBTS. You must provide the most recent value for each asset and balance owed for each debt. Do not leave any category blank. For each item, if none, put “NONE.” If you do not know exact figures for any item, give your best estimate, and put “EST.” If more space is needed, add additional pages. AFFIDAVIT OF PROPERTY AND DEBT Affidavit of _________________________________ (Print Name) I. REAL ESTATE INTERESTS Address Present Fair Market Value Titled To Mortgage Balance Equity 1.__________________________ $ _______________ $ $ __________________________ _______________ $ $ 2.__________________________ $ __________________________ TOTAL SECTION I: REAL ESTATE INTERESTS: $ II. OTHER ASSETS Category Description Titled To Value A. Vehicles and Other Certificate of Title Property (Include model and year of automobiles, trucks, motorcycles, boats, motors, motor homes, trailers, ATVs, snowmobiles, jet skis, etc.) 1. ____________________________ _____________________________ ________________ $
Category Description Titled To Value ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________ ________________ $ _______________ 5. ____________________________ _____________________________ ________________ $ _______________ 6. ____________________________ _____________________________ B. Financial Accounts (Include checking, savings, CDs, POD accounts, money market accounts, etc.) ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________ C. Pensions & Retirement Plans (Include profit-sharing, IRAs, 401(k) plans, etc. Describe each type of plan) ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________ D. Publicly Held Stocks, Bonds, Securities & Mutual Funds (Name of company and number of shares) ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________
Category Description Titled To Value E. Closely Held Stocks & Other Business Interests and Name of Company (Type of ownership and number of shares) ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ (Insured Life) Cash Value and Loan Balance, if any F. Life Insurance (Company Name and Term or Whole Life) ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________ G. Furniture & Household Goods, Furnishings, and Appliances ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________ H. Safe Deposit Box (Give location and contents) ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________ (If necessary, attach additional pages) I. All Other Assets Not Listed Above (including jewelry, art, tools, firearms, and other collectibles) ________________ $ _______________ 1. ___________________________ _____________________________ ________________ $ _______________ 2. ___________________________ _____________________________
III. SEPARATE PROPERTY CLAIMS Separate property includes, but is not limited to, property owned before marriage and gifts or inheritances to only one spouse. Description Why do you claim this as separate property? Present Fair Market Value ________________ $ _______________ 1. ____________________________ _____________________________ ________________ $ _______________ 2. ____________________________ _____________________________ ________________ $ _______________ 3. ____________________________ _____________________________ ________________ $ _______________ 4. ____________________________ _____________________________ TOTAL SECTION III: SEPARATE PROPERTY CLAIMS: $ _______________ IV. DEBT List ALL OF YOUR DEBTS, your spouse’s debts, and any joint debts. Do not leave any category blank. For each item, if none, put “NONE.” If you don’t know exact figures for any item, give your best estimate, and put “EST.” If more space is needed to explain, please attach an additional page with the explanation and identify which question you are answering. Monthly Payment A. Secured Debt (Mortgages, Car, etc.) Type Name of Creditor Name on Account Total Debt Due ____________ $___________ $___________ 1. __________________________ _________________________ ____________ $___________ $___________ 2. __________________________ _________________________ ____________ $___________ $___________ 3. __________________________ _________________________ ____________ $___________ $___________ 4. __________________________ _________________________ ____________ $___________ $___________ 5. __________________________ _________________________ B. Unsecured Debt (Credit cards, medical bills, other debts) ____________ $___________ $___________ 1. __________________________ _________________________ ____________ $___________ $___________ 2. __________________________ _________________________ ____________ $___________ $___________ 3. __________________________ _________________________
Type Name of Creditor Name on Account Total Debt Due Monthly Payment ____________ $___________ $___________ 4. __________________________ _________________________ ____________ $___________ $___________ 5. __________________________ _________________________ TOTAL SECTION IV: DEBT: $ ___________ V. BANKRUPTCY Filed by Date of Filing Date of Discharge or Relief from Stay Type of Case (Ch. 7, 11, 12, 13) Current Monthly Payments ____________ $___________ $___________ 1. __________________________ _________________________ ____________ $___________ $___________ 2. __________________________ _________________________ TOTAL SECTION V: BANKRUPTCY: $ ___________ OATH OR AFFIRMATION (Do not sign until Notary Public is present) I, (print name), swear or affirm that I have read this Affidavit and, to the best of my knowledge and belief, the facts and information stated in this Affidavit are true, accurate, and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your Signature STATE OF _____________________)) SS COUNTY OF ___________________) Sworn to or affirmed before me by this day of,. __________________________________ Signature of Notary Public __________________________________ Printed Name of Notary Public (Affix seal here) Commission Expiration Date: ___________