PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE ESTATE OF _______________________________________________________, DECEASED CASE NO.______________________________ REPRESENTATION OF INSOLVENCY [R.C. 2117.15] The fiduciary states that the decedent died on ______________________________________________. The fiduciary states that: there is a surviving spouse and no minor children of the decedent who are not the children of the surviving spouse, and an “Application for Family Allowance” (Standard Probate Form 7.1) has been filed, or there is a surviving spouse and minor children of the decedent who are not the children of the surviving spouse and an “Application for Apportionment of Family Allowance” (Standard Probate Form 7.2) has been filed, or there is no surviving spouse and more than one minor child of the decedent and an “Application for Apportionment of Family Allowance” (Standard Form 7.2) has been filed. an election has been made to take the mansion house, other real property and/or tangible personal property as part of the allowance for support. It is unnecessary to liquidate these assets. The fiduciary states that the Inventory and Schedule of Assets have been filed and approved. The fiduciary states that the time for filing claims has expired, and that claims against the estate, either presented or secured, are in the sum of $_____________________, and there are no known contingent claims. The fiduciary states that the Schedule of Claims is attached, and that all claims have been listed by priority pursuant to R.C. 2117.25. The fiduciary states that the assets of the estate to the extent necessary have been liquidated. The estate consists of: a mansion house $__________________________. other real property $____________________________. tangible personal property $_________________________. intangible personal property $___________________________. FORM 24.0 – REPRESENTATION OF INSOLVENCY Effective Date: January 1, 2012 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ___________________ The fiduciary states that the claims against the estate exceed the assets of the estate and that the estate appears to be insolvent. The fiduciary applies to this Court to set this matter for further hearing and instructions as to the priority of and the payment of claims. _______________________________________________________ __________________________________________________ Attorney for Fiduciary Fiduciary _________________________________________________ Typed or Printed Name _____________________________________________ Typed or Printed Name _________________________________________________ Address _____________________________________________ Address _________________________________________________ _____________________________________________ _________________________________________________ Phone Number (include area code) _____________________________________________ Phone Number (include area code) Attorney Registration No. ________________________________________ FORM 24.0 – REPRESENTATION OF INSOLVENCY PAGE 2 Effective Date: January 1, 2012 American LegalNet, Inc. www.FormsWorkFlow.com