Close Corporation Valuation Form {18}

ET 18 Rev. 7/03 Estate Tax Unit P.O. Box 183050 Columbus, OH 43218-3050 1-(800) 977-7711 tax.ohio.gov Close Corporation Valuation Form Estate of: Decedent's last name Decedent's first name and initial Date of death County in Ohio Case number Decedent's Social Security number Name of corporation Item I. Preferred Stock The number of shares of preferred stock owned by decedent pany's preferred stock per share for the past five years are as follows: Year ending Dividends per share . The book values and dividends of said com- Book value per share Based on following number of shares then outstanding The preferred stock has a par value of $ per share. The nominal dividend rate is %. It is cumulative , noncumulative , participating . The amount of accumulated dividends as of the date of death on the above preferred stock was $ . This stock is callable , noncallable . Item II. Common Stock The number of shares of common stock owned by decedent pany's common stock per share for the past five years are as follows: Year ending Dividends per share . The book values and dividends of said com- Book value per share Based on following number of shares then outstanding The common stock has a par value of $ per share. American LegalNet, Inc. www.FormsWorkFlow.com ET 18 Rev. 7/03 Page 2 Item III. Statement of Earnings The following is a statement of the profit or loss (after income tax but before dividends) for the last five years indicated and also a statement representing earnings per share for said common stock: Year ending Net profit (or loss)a Earnings per shareb Based on following number of shares then outstanding (a) Do not deduct any dividends paid during year. (b) To arrive at the earnings per share for common stock, deduct dividend requirements of preferred stock and divide remainder by the number of shares of common stock then outstanding. Item IV. Sales Evidence The following is a list of the sales of the corporate stock, made within a reasonable period of time prior to and/or after the date of death. Shares Sold Common/Preferred Number Date Price Seller Buyer Broker Item V. Incorporation Data Incorporated under the state of Principal place of business (street address, city, state, ZIP code) Nature of business (If additional space is needed, use Additional Comments section on page 3.) President Vice president Treasurer Secretary When being first duly sworn deposes and says that he/she is the President, Vice president, Treasurer, Secretary of the corporation and that he/she has examined the books and records of said company that disclose the above facts; that the same represents a true copy of the records of said corporation. Signature of officer Sworn to and subscribed before me this day of , 20 . Title Notary public American LegalNet, Inc. www.FormsWorkFlow.com ET 18 Rev. 7/03 Page 3 Additional comments Item VI. Additional Information This information is needed in order to make a fair evaluation of the corporation. The appropriate NAICS (North American Industry Classification System) code: Briefly summarize: 1. Company operations 2. Company history and present status 3. Economic outlook of industry American LegalNet, Inc. www.FormsWorkFlow.com ET 18 Rev. 7/03 Page 4 4. Share of market 5. Economic outlook of status of business Item VII. Method Used in Valuation Please provide a detailed outline of the valuation method American LegalNet, Inc. www.FormsWorkFlow.com