TED KLAMMER, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO ESTATE OF ___________________________________________________________, DECEASED CASE NO. ______________________ ASSETS AND LIABILITIES OF ESTATE TO BE RELIEVED FROM ADMINISTRATION The following is a summary statement of the character and value of the assets in decedent’s estate [Insert a check in the “Appraised” column opposite an item if it was valued by the appraiser. Leave blank if the readily ascertainable value of the item was determined by applicant. Use extra sheets if necessary.] __________________________________________________________________________________ Automobiles distributed to surviving spouse by affidavit Value First automobile selected by surviving spouse under R.C. 2106.18 [Omit value when computing total assets]…………..Appraised value $ Second automobile selected by surviving spouse under R.C. 2106.18 [Omit value when computing total assets]…………..Appraised value $ Total Value [not to exceed $40,000.00] $ Character of asset Real Estate, described in accompanying Certificate of Transfer No. Other assets Appraised Value $ $ Prepared by Attorney’s Name__________________________ Address_________________________________ Phone No._______________________________ FORM 5.1-ASSETS AND LIABILITIES OF ESTATE TO BE RELIEVED FROM ADMINISTRATION American LegalNet, Inc. www.FormsWorkFlow.com [Side 2 of FORM 5.1] __________________________________________________________________________________ Name of Creditor Nature of Debt Amount $ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Total Debts $ CERTIFICATION The undersigned appraiser agreed to act as appraiser of decedent’s estate, and to appraise the property exhibited truly, impartially, and to the best of the appraiser’s knowledge and ability. The appraiser further says that those assets whose values were not readily ascertainable are indicated above by a check in the “Appraised” column opposite each such item, and that such values are correct. The undersigned applicant determined the value of those assets whose values were readily ascertainable and were not appraised by the appraiser, and that such values are correct, and to applicant’s knowledge the above list of decedent’s debts is correct. _______________________________ Date _______________________________ Appraiser _______________________________ Applicant American LegalNet, Inc. www.FormsWorkFlow.com