IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY IN THE MATTER OF THE ESTATE CASE NO: _____________________ OF: , DECEASED SCHEDULE OF CLAIMS [R.C. §§2117.17, .25] [Use extra sheets if necessary] The fiduciary says that to his knowledge this schedule lists all claims against decedent or his estate. Such claims are recapitulated as follows: Claims allowed Claims rejected, contingent, or in suit Total $____________ $____________ $____________ ___________________________________ ______________________________________ Attorney Fiduciary Supreme Court No. ______________________ [Under “Footnotes” opposite an item requiring explanation, place the number of the appropriate footnote. Such notes should be included on the reverse to explain any security for claims, maturity dates of claims not due, contingent claims, claims in suit, and dates of rejection of rejected claims.] Name and Address of Claimant Amount Claimed Payment Class Date Presented FootNotes $ $ $ $ $ $ $ $ $ $ $ Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com CASE NO: _________________ Name and Address of Claimant Amount Claimed Payment Class Date Presented FootNotes $ $ $ $ $ $ $ $ $ $ $ $ FOOTNOTES Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com