COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS HAMILTON COUNTY, OHIO Plaintiff / Petitioner Date: Case No. -vs/and- File No. CSEA No. Defendant / Petitioner Property Statement NOTICE OF SCHEDULING CONFERENCE A HEARING WILL BE HELD ON The _____________ day of ____________________________________, 20_______ , at ______________.M. before Magistrate ___________________________________________, Room ______________, Domestic Relations Court, 800 Broadway, Cincinnati, Ohio 45202-1332. ---------------------------------------------------------------------------------------------MOTION FOR FINAL DETERMINATION OF ISSUES (Check and Sign if Applicable) _____ Plaintiff represents to the Court that the issues to be decided are limited. In the event that Defendant fails to answer or appear for the scheduling conference, Plaintiff requests that the Court make all such final orders including all parenting orders, child support, spousal support, attorney fees and costs, and a division of property as are necessary and appropriate to the resolution of this matter on the above date and time. Plaintiff further represents that all requisite discovery will be completed prior to the hearing date. ______________________________________ Plaintiff/Attorney for Plaintiff ---------------------------------------------------------------------------------------------INSTRUCTIONS Pursuant to O.R.C. §3105.171 (B) every asset and liability, both marital and separate property, is subject to the jurisdiction of the Court. Therefore, every asset and liability of either party must be listed. Pursuant to O.R.C. §3105.171 (A) (2) “during the marriage” for purposes of identifying marital property is defined as from the date of marriage to the date of final hearing “unless it would be inequitable to use such dates.” For purpose of this property statement “during the marriage” is defined as the following dates: ______________________________ (date of marriage). _____________________________________________________________________________________________ (other) to _____________________________ (date of separation), _________________________________________________(date of filing complaint) __________________________ (date of final hearing) ______________________________________________ (other specify) _____________________________________. Date of Valuation used for purpose of this statement ______________________________________________ 1: REAL ESTATE Address/Title Appraisal/ Market Value Marital/Separate Mixed Source of Valuation Equity __________________________________ _______________ ___________________ ______________ _______________ __________________________________ _______________ ___________________ ______________ _______________ __________________________________ _______________ ___________________ ______________ _______________ Comment: ____________________________________________________________________________________________________ 2: HOUSEHOLD GOODS (Please attach inventory of property claimed to be separate as well as marital property for which you request an individual award. If all household goods are to be divided equally, please so indicate.) Comment: ____________________________________________________________________________________________________ DR 4.1 (July, 2001) Pg. 1 American LegalNet, Inc. www.FormsWorkflow.com 3: AUTOMOBILES Appraisal or Current Market Price Marital/Separate Mixed Source of Valuation Equity Description/Title Year & Make ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ Comment: ____________________________________________________________________________________________________ 4: FUNDS ON DEPOSIT Description/Title Type of Account Number Marital/Separate Mixed __________________________________ _____________________ ___________________ _______________________ __________________________________ _____________________ ___________________ _______________________ __________________________________ _____________________ ___________________ _______________________ Comment: ____________________________________________________________________________________________________ 5: STOCKS AND BONDS Appraisal or Current Market Price Source of Valuation Location/Title Description/ Number Marital/Separate Mixed __________________________________ _______________ ____________ ___________________ _________________ __________________________________ _______________ ____________ ___________________ _________________ __________________________________ _______________ ____________ ___________________ _________________ Comment: ____________________________________________________________________________________________________ 6: RETIREMENT SAVINGS PLANS/PENSIONS/PROFIT SHARING Year of Name of Plan/Employer Employment Years in Plan Vested? Amount Marital/Separate Mixed H: _____________________________ ______________ _____________ _______ ________ _________________ W: _____________________________ ______________ _____________ _______ ________ _________________ Comment: ____________________________________________________________________________________________________ 7: TAX REFUNDS Year Source Present Value Date of Receipt Marital/Separate Mixed H: __________________________ ______________ _________________ _______________ _________________ W: __________________________ ______________ _________________ _______________ _________________ J: ___________________________ ______________ _________________ _______________ _________________ How many tax exemptions are you presently claiming, including yourself? _________________________________________________ 8: LIFE INSURANCE Name of Company Policy No. Insured Owner Beneficiary Face Amount Cash Value Marital/Separat e Mixed ______________________ __________ _________ __________ __________ _________ _______ ______________ ______________________ __________ _________ __________ __________ _________ _______ ______________ ______________________ __________ _________ __________ __________ _________ _______ ______________ Comment: _________________________________________________________________________________________ 9: EXPECTANCIES AND INHERITANCES OF THE PARTIES Location/Titled _______________________________ Value of Fund ________________ Date of Valuation __________________ Source of Valuation _____________ Marital/Separate Mixed ____________________ Comment: ____________________________________________________________________________________________________ 10: OTHER ASSETS List location, title, value of item including date and source of valuation, including whether this property is claimed to be marital, separate, or mixed. DR 4.1 (July, 2001) Pg. 2 American LegalNet, Inc. www.FormsWorkflow.com _____________________________________ $______________________ __________________________________ _____________________________________ $______________________ __________________________________ _____________________________________ $______________________ __________________________________ _____________________________________ $______________________ __________________________________ LIABILITIES Name of Creditor Encumbrance Who is Liable: Husband, Wife Bal. Due As of Marital/Sep/ Mixed 1: _________________________ _____________ _____________ __________ _______ ______________ 2: _________________________ _____________ _____________ __________ _______ ______________ 3: _________________________ _____________ _____________ ___________ _______ ______________ 4: _________________________ _____________ _____________ ___________ _______ ______________ 5: _________________________ _____________ _____________ ___________ _______ ______________ 6: _________________________ _____________ _____________ ___________ _______ ______________ 7: _________________________ _____________ _____________ ___________ _______ ______________ 8: _________________________ _____________ _____________ ___________ _______ ______________ Comment: ____________________________________________________________________________________________________ Total Asset Value minus Total Liabilities equals Total Equity ___________________________________________________________ STATE OF OHIO COUNTY OF HAMILTON } } } S.S. ___________________________________, being first duly cautioned and sworn, deposes and states that the facts set forth in the foregoing Property Statement are true as he / she verily believes. _____________________________________________ Sworn to and subscribed in my presence this ______________________ day of ____________________________________ 20 ________ . _____________________________________________ Notary Public PROOF OF SERVICE _______ I hereby certify that a copy of the foregoing property statement has this ____________________________________________ day of __________________________________, 20_____, been served by _______________________________________________ upon ________________________________________________________________________________________________________ _________ Service has been requested through the Clerk of Courts. _____________________________________________ Plaintiff / Defendant Attorney for Plaintiff / Defendant DR 4.1 (July, 2001) Pg. 3 American LegalNet, Inc. www.FormsWorkflow.com