Please provide a copy of this form to: Ashland Co. Common Pleas Court 142 W. Second Street Ashland, Ohio 44805 Owner's Financial Information For Foreclosure Mediation DELIVER THIS FORM TO THIS LENDER: Case Number(s) DO NOT FILE WITH THE CLERK OF COURTS Owner Name Property Address This property is my primary residence. Yes No I want to continue living in this property. Yes Yes No No I am interested in discussing options other than remaining in this property. EMPLOYMENT INFORMATION Homeowner Name, Address and Phone Number Self Employed Yrs. on this job Employer and Position Business Phone ( Co-Owner Name, Address and Phone Number Self Employed ) Yrs. on this job Empoyer and Position Business Phone ( GROSS MONTHLY INCOME OWNER 1 OWNER 2 ) OWNER 1 OWNER 2 MONTHLY INCOME AND SALARY INFORMATION GROSS MONTHLY INCOME Base Employment Income Overtime Bonuses Commissions Dividends/Interest Net Rental Income ASSETS Checking, Savings, and other accounts Amount/Value Retirement Income/Pension Disability Payments Social Security Child Support Spousal Support Other Income REAL ESTATE/RENTAL PROPERTY ADDRESS VALUE AUTOMOBILES/VEHICLES VEHICLE VALUE American LegalNet, Inc. www.FormsWorkFlow.com LIABILITIES (Please include all living expenses) Creditor Name Amount Owed CIVIL JUDGMENTS AND CIVIL JUDGMENTS DECREES OF DIVORCE/DISSOLUTION Creditor Name Amount I affirm that the information provided is true and accurate to the best of my knowledge. Owner 1 print name: Owner 1 Signature: Owner 2 print name: Owner 2 Signature: DOCUMENT CHECKLIST Please provide the following documents to the Mediator and the Creditor AT LEAST 30 days prior to mediation. It WILL help in reaching a solution. Copies may be substitued for original documents. Use this checklist to organize your documents. You should ALSO bring an EXTRA copy of the documents when the mediation is scheduled, to make sure they are available then. Financial Account Information Copy of last 3 statements of your savings account(s) Copy of last 3 statements of your checking account(s) Copy of last 3 statements of your brokerage account(s) Copy of last 3 statements of your retirement account(s) Salary/Income Pay stubs for the last 2 months Year to date profit/loss statement if you are self employed Lease agreement for any rental property that you own Copy of most recent W-2R Annual statement for your insurance policy Tax Information Tax returns for the last 2 years W-2 forms for the last 2 years Copy of tax schedule for any rental property that you own or have an interest Copy of most recent SSA-1099 Social Security year end income statement American LegalNet, Inc. www.FormsWorkFlow.com