COURT OF COMMON PLEAS COUNTY, OHIO Case No. Plaintiff/Petitioner Judge v./and Magistrate Respondent/Petitioner Instructions: Check local court rules to determine when this form must be filed. List ALL OF YOUR PROPERTY AND DEBTS, the property and debts of your spouse, and any joint property or debts. Do not leave any category blank. For each item, if none, put "NONE." If you do not know exact figures for any item, give your best estimate, and put "EST." If more space is needed, add additional pages. AFFIDAVIT OF PROPERTY Affidavit of (Print Your Name) I. REAL ESTATE INTERESTS Address Present Fair Market Value $ Titled To Husband Wife Both Husband Wife Both Mortgage Balance $ $ Equity (as of date) 1. 2. $ $ $ TOTAL SECTION I: REAL ESTATE INTERESTS $ Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 2 Affidavit of Property Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 7 II. OTHER ASSETS Category A. Vehicles and Other Certificate of Title Property Description (List who has possession) (Include model and year of automobiles, trucks, motorcycles, boats, motors, motor homes, etc.) Titled To Value/Date of Value 1. Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both $ $ 2. $ 3. $ 4. $ 5. $ 6. (Include checking, savings, CDs, POD accounts, money market accounts, etc.) B. Financial Accounts 1. Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both $ $ 2. $ 3. $ 4. Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 2 Affidavit of Property Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Category C. Pensions & Retirement plans Description (List who has possession) (Include profit-sharing, IRAs, 401k plans, etc.; Describe each type of plan) Titled To Value/Date of Value 1. Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both D. Publicly Held Stocks, Bonds, Securities & Mutual Funds Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both $ $ 2. $ 3. $ 4. $ 1. $ 2. $ 3. $ 4. Category E. Closely Held Stocks & Other Business Interests and Name of Company Description (List who has possession) (Type of ownership and number) Titled To Value/Date of Value 1. Husband Wife Both Husband Wife Both $ 2. $ Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 2 Affidavit of Property Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7 F. Life Insurance Type (Term/Whole Life) (Any cash value or loans) (Insured party & value upon death) 1. Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both $ 2. $ 3. $ 4. $ Category G. Furniture & Appliances Description (Estimate value of those in your possession, and value of those in your spouse's possession) Who Has Possession Value/Date of Value 1. Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both $ $ 2. $ 3. $ 4. (Give location and describe contents) H. Safe Deposit Box Titled To Husband Wife Both Husband Wife Both $ 1. $ 2. Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 2 Affidavit of Property Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 7 I. Transfer of Assets Explanation: List the name and address of any person (other than creditors listed on your Affidavit) who has received money or property from you exceeding $300 in value in the past 12 months and the reason for each transfer. 1. Husband Wife Both Husband Wife Both Husband Wife Both Husband Wife Both $ $ 2. $ 3. $ 4. Category J. All Other Assets Not Listed Above Description (Also list who has possession) Explanation: List any item you have not listed above that is considered an asset. Titled To Value/Date of Value 1. Husband Wife Both Husband Wife Both $ $ 2. TOTAL SECTION II: OTHER ASSETS $ III. SEPARATE PROPERTY CLAIMS: Pre-marital assets, gifts to one spouse only, inheritances If you are making any claims in any of the categories below, explain the nature and amount of your claim. This includes, but is not limited to, inheritances, property owned before marriage, and any pre-marital agreements. Category (Pre-marital Gift, Inheritance, etc., acquired after separation) Description Why do you claim this as a separate property? $ $ $ $ $ Present Fair Market Value 1. 2. 3. 4. 5. TOTAL SECTION III: SEPARATE PROPERTY CLAIMS $ Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 2 Affidavit of Property Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 7 IV. DEBT List ALL OF YOUR DEBTS, the debts of your spouse, and any joint debts. Do not leave any category blank. For each item, if none, put "NONE." If you don't know exact figures for any item, give your best estimate, and put "EST." If more space is needed to explain, please attach an additional page with the explanation and identify which question you are answering. Name of Creditor/Purpose of Debt Name(s) on Account Total Debt Due Monthly Payment Type A. Secured Debt (Mortgages, Car, etc.) Account Name 1. Husband Wife Joint Husband Wife Joint Husband Wife Joint Husband Wife Joint Husband Wife Joint $ $ 2. $ $ 3. $ $ 4. $ $ 5. $ $ B. Unsecured Debt, including credit cards Husband Wife Joint Husband Wife Joint Husband Wife Joint Husband Wife Joint Husband Wife Joint 1. $ $ 2. $ $ 3. $ $ 4. $ $ 5. $ $ $ TOTAL SECTION IV: DEBT Supreme Court of Ohio Uniform Domestic Relations Form ­ Affidavit 2 Affidavit of Property Approved under Ohio Civil Rule 84 Effective Date: July 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 7 V. BANKRUPTCY Filed by: Wife, Husband, Both 1. Husband Wife Both Husband Wife Both Date of Filing: Case Number Date of Discharge or Relief from Stay Type of Case (Ch. 7, 11, 12, 13) Current Monthly Payments $ 2. $ TOTAL SECTION V: BANKRUPTCY $ OATH (Do Not Sign Until Notary is Present) I, (print name) swear or affirm that I have read this document and, to the best of my knowledge and belief, the facts and information stated in this document are true, accurate and complete. I understand that if I do not tell the truth, I may be subject to penalties for perjury. Your Signature Sworn before me and signed in my presence this day of , . Notary Public My Commission Expi