IN THE COURT OF COMMON PLEAS OF FRANKLIN COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS CASE NO. SOCIAL SECURITY # Plaintiff/Petitioner ASSETS AND LIABILITIES vs. AS OF (Date) SOCIAL SECURITY # Defendant/Petitioner Instructions:You must disclose all information requested herein pursuant to Court Rule 17 of the Franklin County Court of Commons Pleas, Division of Domestic Relations. List all assets, liabilities, income sources and retirement accounts separately. Also list value of all assets and whether assets or liabilities are jointly or individually held. This may be supplemented with additional information on attached sheets. ASSETS: CONTINGENT LIABILITIES: Cash Notes/AccountsPayable: Government Bonds Guarantor: Checking Accounts: Other Contingent Savings Accounts: Liabilities: Accounts/Notes LIABILITIES: Receivable: Notes Payable: Stocks, Bonds, Securities: Accounts Payable: Life Insurance Cash Values: Loans on Life Ins.: Real Estate: Taxes: Automobiles: Mortgages: Other Assets (itemize): Debts: Individual Name: Income: Gross Income from Employment: weekly monthly annually Other Income (itemize): Joint Name: Retirement Accounts, Pensions, 401K Accounts, etc.: Husband: Vested: yes no Wife: Vested: yes no Plaintiff/Defendant/Petitioner Sworn to and subscribed by the Plaintiff/Defendant/Petitioner before me this dayof 20 . Notary Public COC-DR-05 (Rev. 3-2000)