Statement As To Creditors

IN THE MUNICIPAL COURT OF PERRYSBURG, WOOD COUNTY, OHIO * * * * * * * * * * Debtor/Applicant Name Street Address City/State/Zip Phone Number Social Security Number Case No. ______________________ STATEMENT AS TO CREDITORS (SECURED AND UNSECURED) *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** *** Ohio Revised Code 2329.70 The following is a full, accurate, and complete statement to the date of filing hereof of the names of the secured and unsecured creditors of the undersigned with liquidated claims, their addresses, and amount due and owing to each: CREDITOR NAME ADDRESS ACCOUNT# AMOUNT DUE AND OWING Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CREDITOR NAME ADDRESS ACCOUNT# AMOUNT DUE AND OWING State of Ohio, Wood County The undersigned being duly sworn says that the foregoing statement is full, accurate, and complete. ______________________________________ Debtor/Applicant Sworn to before me and signed in my presence this _____ day of ____________, 20___. ______________________________________ Notary Public Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com