Affidavit {C2}

PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE IN THE MATTER OF: CASE NO.: AFF IDAVIT I, ________________________________________ the undersigned, state that the following represents a true and accurate accounting of my incomassets and liabilities: e, 1. INCOME: Wages, interest, government checks, etc. . $ __________ Are you currently working?  YES  NO Are you married?  YES  NO Number of dependents (list): Does your spouse work?  YES  NO Spouses income .. $ __________ 2. OWNER OF REAL PROPERTY?  YES  NO Description: Address: In whose name ? Estimated Value $ __________ Amount and holder of mortgage $ __________ Annual income from real property, if any $ __________ Is this property owned by the estate?  YES  NO If so, what %? .. % __________ 3. OWNER OF AUTOMOBILE?  YES  NO Make ____________________________________ Model In whose name registered Present estimated value of automobile . .$ __________ Amount owed on said automobile .$ __________ Owed to . D.3.- PAGE 1 OF FORM LUCAS COUNTY PROBATE COURT C-2 MODIFIED AFFIDAVIT EFF: 6/05 American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 CASE NO.: 4. CASH ON HAND: $ __________ Cash in bank and savings accounts ...$ __________ Names and addresses of banks 5. OTHER ASSETS: (State other investments, recreational vehicles, or items of personal property, except basic furnishings and necessities). $ __________ $ __________ $ __________ $ __________ $ __________ 6. LIABILITIES: Monthly rental on house or apartment .. $ __________ Monthly mortgage payments $ __________ Monthly payments on car . $ __________ Other monthly payments: $ __________ $ __________ $ __________ $ __________ $ __________ OTHER OBLIGATIONS: $ __________ $ __________ 7. TOTAL ESTIMATED VALUE OF DECEDENTS OR WARDS ESTATE Real Property (describe) $ __________ Cash (list accounts) $ __________ $ __________ $ __________ Other personal property (list) $ __________ $ __________ $ __________ PAGE 2 OF FORM LUCAS COUNTY PROBATE COURT C-2 MODIFIED AFFIDAVIT American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 CASE NO.: The real property described above will be disposed of as follows:  Transferred to  Transferred to surviving spouse  Sold Does the surviving spouse presently live in the real property?  YES  NO Does the surviving spouse plan to continue to live in the real property?  YES  NO 8. If Court Costs are to be paid at a later date, please estimate date and describe course Signed: Date: I, _______________________, Attorney-at-law, hereby certify, that the within instrument was prepared and/or examined by me, and that the same, in my opinion, is correct and proper. PAGE 3 OF FORM LUCAS COUNTY PROBATE COURT C-2 MODIFIED AFFIDAVIT American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com