Barberton Municipal Court 576 West Park Avenue, Room 205 Barberton, Ohio 44203 (330) 861-7192 www.cityofbarberton.com/clerkofcourts DEBTOR DISCLOSURE FORM Barberton Municipal Court Case No: Judgment Date: Amount of Judgment, Including Court Costs: $ Judgment Creditor Judgment Debtor Name: Name: Address: Address: Phone: Phone: Debtor : (Please complete the following form): Social Security Number: Place of Employment: Address of Employer: Amount of Earnings: $ Weekly Monthly Assets: Real Estate: Yes No Location: Bank Accounts: Name of Bank: Account No: Checking Savings Motor Vehicle: Auto Truck Other Year Model Make Color License VIN No Liabilities: S ection 1925.13(B): If, within thirty (30) days after judgment is not satisfied, and the parties have not otherwise agreed the Court shall, upon the request of the Judgment Creditor, order the Judgment Debtor to file, on a form prepared by the Court, a list of assets, liabilities, and personal earnings. The form shall contain a notice that FAILURE TO COMPLETE THIS FORM AND R ETURN IT TO THE COURT AT THE ADDRESS ABOVE WITHIN ONE (1) WEEK AFTER RECEIPT MAY RESULT IN A CITATION FOR CONTEMPT OF COURT. Any party who, with notice of this possible contempt citation, willfully fails to comply with the order of the Court, may be cited for contempt of Court, as provided in Chapter 2795 o f the Ohio Revised Code. American LegalNet, Inc. www.USCourtForms.com