Lorain County Probate Court Judge James T. Walther ESTATE OF __________________________________________________________, DECEASED CASE NO. ______________________ APPLICATION FOR CERTIFICATE OF TRANSFER [R.C. 2113.61] Applicant states that decedent died on _________________________________________________________________ Decedent's residence at death was _____________________________________________________________________ Street Address _________________________________________________________________________________________________ County City or Village, or Township if unincorporated area _________________________________________________________________________________________________ State Zip Code Post Office Decedent died owning the real property described in the accompanying Certificate of Transfer No. ________, which also lists those persons to whom the real property passed. Applicant asks the Court to issue a Certificate of Transfer so that new ownership interests may be recorded. [Check the applicable boxes] Decedent died intestate. Decedent died testate on _________________________; will admitted to probate on ______________________________. Decedent's known debts have been paid or secured to be paid. Sufficient other assets are in hand to pay decedent's known debts. Estate is insolvent and the transfer shall apply toward the allowance for support. Applicant was appointed by this Court on ______________________________________ and is the qualified and acting executor or administrator of decedent's estate. Executor or administrator of decedent's estate failed to file this application before being discharged. Applicant is the executor or administrator appointed in another state. There is and has been no ancillary administration in Ohio. The real property to be transferred is located in this county. The transfer is subject to a written contract for the sale and conveyance of the real property, entered into but uncompleted by decedent before death. A copy of the contract is attached. The transfer is pursuant to decedent's Will. The transfer is pursuant to the statutes of descent and distribution. The real property to be transferred is subject to a charge in favor of the surviving spouse in the amount of $ ____________ as computed pursuant to R.C. 2106.11 on attached Exhibit A, and as shown on the accompanying Certificate of Transfer, in respect of the unpaid balance of the specific monetary share which is part of the surviving spouse's total intestate share. FORM 12.0 - APPLICATION FOR CERTIFICATE OF TRANSFER 10/1/98 American LegalNet, Inc. www.FormsWorkFlow.com (Reverse of Form 12.0) The transfer is of decedent's entire interest in the mansion house to the surviving spouse, who hereby elects to take such interest as part or all of the intestate share and/or allowance for support. [If this paragraph is checked, the following must be completed, and both the surviving spouse and applicant must sign this form]. The value of the total intestate share to which decedent's surviving spouse is entitled is ................. $___________________ The value of the allowance for support to which decedent's surviving spouse is entitled is .............. $___________________ The value of decedent's entire interest in the mansion house is: Interest in mansion house ................................................. $ ______________________ Interest in household goods in house................................ $ ______________________ Interest in lots or farm land adjacent to house and used in conjunction with it, which are described in certificate of transfer and which spouse hereby elects to include ........................................ $ ______________________ Less: Decedent's share of liens on any and all of above ........................................ $ ______________________ Total ................................................................$ ______________________ _____________________________________ Surviving Spouse $ ___________________ ______________________________________________________ Applicant _____________________________________________________ Title or status ENTRY ISSUING CERTIFICATE OF TRANSFER The Court finding that the above application contains the information required by statute orders that Certificate of Transfer No. _____ be filed with this Entry and a copy of the Certificate of Transfer be issued for recording. [ ] [Check if applicable] The Court further finds that the transfer is subject to a charge pursuant to R. C. 2106.11. _______________________________________ Date ______________________________________________________ Judge American LegalNet, Inc. www.FormsWorkFlow.com