IN THE DELAWARE MUNICIPAL COURT Small Claims Division JUDGMENT DEBTOR FINANCIAL DISCLOSURE FORM DELAWARE MUNICIPAL COURT JUSTICE CENTER 70 NORTH UNION STREET DELAWARE, OHIO 43015 SMALL CLAIMS DIVISION (740) 203-1560 FAX NO. (740) 203-1599 www.municipalcourt.org NAME OF PLAINTIFF vs. CASE NO. AMOUNT OF JUDGMENT: $ NAME OF DEFENDANT NOTICE TO THE JUDGMENT DEBTOR: JUDGMENT HAS BEEN ENTERED AGAINST YOU IN THE AMOUNT SHOWN IN THE ABOVE REFERENCED CASE. THE JUDGMENT CREDITOR HAS REQUESTED THIS COURT TO ORDER YOU TO PROVIDE INFORMATION ABOUT YOUR FINANCIAL STATUS. YOU ARE INSTRUCTED TO COMPLETE THIS FORM IN ITS ENTIRETY. WHERE A GIVEN LINE IS NOT APPLICABLE TO YOU, YOU ARE TO MARK THE LINE “N/A”. WHERE INSUFFICIENT SPACE IS PROVIDED, YOU ARE TO ATTACH LINED NOTEBOOK PAPER TO INCLUDE THE FULL INFORMATION REQUESTED. FAILURE TO COMPLETE THIS FORM IN ITS ENTIRETY AND RETURN IT TO THE COURT WITHIN ONE (1) WEEK OF RECEIPT MAY RESULT IN A CITATION FOR CONTEMPT OF COURT. A FINDING OF CONTEMPT OF COURT MAY RESULT IN A WARRANT FOR YOUR ARREST AND PENALTIES SUBJECTING YOU TO JAIL, A FINE, OR BOTH. IF YOU HAVE QUESTIONS ABOUT COMPLETING THIS FORM, YOU MAY CONTACT THE COURT AT THE TELEPHONE NUMBER ABOVE. IF YOU HAVE LEGAL QUESTIONS, YOU SHOULD SEEK THE ADVICE OF AN ATTORNEY IMMEDIATELY. 1. BANK ACCOUNTS (LIST ALL ACCOUNTS: Checking, Savings, Money Market, Certificates of Deposit, Individual Retirement Accounts, etc.): Savings: Name of Bank Address Account # Balance Name of Bank Address Account # Balance Checking: 2. VEHICLES (LIST ALL VEHICLES and WATERCRAFT: Cars, Vans, Trucks, Boats, Motorcycles, Snowmobiles, Mopeds, etc.): A. Make Model Year Reg. # Balance owed Lender and Address Make Model Year Reg. # Balance owed Lender and Address Make Model Year Reg. # Balance owed Lender and Address B. C. 3. REAL PROPERTY (LIST ALL PROPERTY OWNED BY YOU: Houses, Condominiums, Land, etc.): A. Address Purchase Price Balance Owed Lender and Address Address Purchase Price Balance Owed Lender and Address B. 4. SIGNIFICANT PERSONAL PROPERTY (VCR, TV, Stereo, Major Appliances, Tool Sets, Furniture, Art, Computers, China, Jewelry, etc.) A. Type of Property Location Purchase Price Balance Owed Lender and Address Type of Property Location Purchase Price Balance Owed Lender and Address B. -CONTINUED ON OTHER SIDEFORM C Revised April 16, 2007 American LegalNet, Inc. www.FormsWorkflow.com 4. SIGNIFICANT PERSONAL PROPERTY, CONTINUED C. Type of Property Location Purchase Price Balance Owed Lender and Address Type of Property Location Purchase Price Balance Owed Lender and Address Type of Property Location Purchase Price Balance Owed Lender and Address D. E. 5. OTHER FINANCIAL ASSETS (Stocks, Bonds, Accounts Receivable, Annuities, etc.): A. Type of Property Location Est. Market Value Holder, Address, and Account # Type of Property Location Est. Market Value Holder, Address, and Account # Type of Property Location Est. Market Value Holder, Address, and Account # B. C. 6. PERSONAL EARNINGS (Salary, Commissions, Tips, etc.): A. Employer, Address, and Phone # Weekly or Monthly Take-Home Pay Employer, Address, and Phone # Weekly or Monthly Take-Home Pay B. JUDGMENT DEBTOR’S CERTIFICATION The undersigned does hereby certify to the Delaware Municipal Court that I have read the Notice on the front of this form and all of the information contained on this form and any attachments hereto are a true and accurate reflection of my assets as stated on the date of this certification. The information contained is provided after a good faith review of all relevant records to determine my true financial status. I understand that if I do not take steps to voluntarily satisfy the judgment in this case, the judgment creditor could proceed against any or all of the assets listed in my answers to this disclosure form. This certification does not constitute a waiver of any defenses, rights, or exemptions I may have in reference to this or any other case. Signature of Judgment Debtor Date Printed Name of Judgment Debtor Address Date of Birth Ohio Driver’s License or ID # -CONTINUED ON OTHER SIDE- FORM C Revised April 16, 2007 American LegalNet, Inc. www.FormsWorkflow.com