PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE ESTATE OF , DECEASED CASE NO. ASSETS AND LIABILITIES OF ESTATE TO BE RELIEVED FROM ADMINISTRATION 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.] Value Automobiles distributed to surviving spouse by affidavit 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 $ XXXX XXXX - Total value [not to exceed $40, 000 00] Character of asset Real Estate, described in accompanying Certificate of Transfer No. XXXX $ Appraised Value $ Other assets Total Assets Page 1 of 2 $ $ FORM 5.1 - ASSETS AND LIABILITIES OF ESTATE TO BE RELIEVED FROM ADMINISTRATION 04/01/97 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. Following is a list of decedent's known debts. [Use extra sheets if necessary] 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, honestly, 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 Page 2 of 2 Applicant FORM 5.1 - ASSETS AND LIABILITIES OF ESTATE TO BE RELIEVED FROM ADMINISTRATION American LegalNet, Inc. www.FormsWorkflow.com