Preview
:
:
IN THE COURT OF COMMON PLEAS
ommestic DIVISION
Clark COUNTY, OHIO
Amiee Collett
Clark County, Ohio
Case No.
240R13
Piaintiff/Petitioner 1 FILED
Judge.
vs./and APR 04 2024
Magistrate
Dylan Lower Common Pleas Court
Defendant/Petitioner 2
Melissa-M. Tuttle, Clerk
Check tocal 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. You must
provide the most recent value for each asset and balance owed for each debt. 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 PROP! ‘le DEBT
Affidavit of Ce’
il ex
I. REAL ESTATE INTERESTS
Addres: Present Fair Titled To Mortgage Balance Eauity
Market Value
TOTAL SECTION I: REAL ESTATE INTERESTS: $§.
ll. OTHER ASSETS
Gategory Description
A. Vehicles and Other Certificate (Include model and year of
of Title Property automobiles, trucks, motorcycles,
boats, motors, motor homes, trailers,
ATVs, snowmobiles, jet skis, etc.)
1
2.
Supreme Court of Ohio Page 1 of 5
Uniform Domestic Relations Form — Affidavit 2
AFFIDAVIT OF PROPERTY AND DEBT
Approved under Ohio Civil Rule 84
Amended: June 1, 2021
B. Financial Accounts (Include checking, savings, CDs,
POD accounts, money market
accounts, etc.)
Chase Coecthind, $28.92
. Sndst SQLS. ¢ OF. 94
C. Pensions & Retirement (Include profit-sharing, IRAs,
Plans 401(k) plans, etc. Describe each
type of plan)
D. Publicly Held Stocks, (Name of company and number of
Bonds, Securities & Mutual shares)
Funds
Supreme Court of Ohio
Uniform Domestic Relations Form — Affidavit 2
AFFIDAVIT OF PROPERTY AND DEBT
Approved under Ohio Civil Rule 84
Amended: XXXX, 2021 Page 2 of 5
Category Description
E. Closely Held Stocks & Other (Type of ownership and number of
Business Interests and Name shares)
of Company
$
$
F. Life Insurance (Company (Insured Life) Cash Value and
Name and Term or Whole Life) Loan Balance, if
any
$
$
$
G. Furniture & Household
Goods, Furnishings, and
Appliances
H. Safe Deposit Box
(Give location and contents)
1. All Other Assets Not Listed (If necessary, attach additional
Above (including jewelry, art, pages)
tools, firearms, and other
collectibles)
$
$
TOTAL SECTION Ii: OTHER ASSETS: $
Supreme Court of Ohio
Uniform Domestic Relations Form — Affidavit 2
AFFIDAVIT OF PROPERTY AND DEBT
Approved under Ohio Civil Rule 84
Amended: XXXX, 2021 Page
3 of 5
Ill SEPARATE PROPERTY CLAIMS
Separate property includes, but is not limited to, property owned before marriage and gifts or inheritances to
only one spouse.
Description Why do you claim Present Fair Market
this as separate Value
property?
$
TOTAL SECTION Ill: SEPARATE PROPERTY CLAIMS: $
IV, DEBT
List ALL OF YOUR DEBTS, your spouse's debts, 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.
Type Name of Creditor Name on Total Debt Monthly
Account Due Payment
A. Secured Debt (Mortgages,
Car, ete.)
B. Unsecured Debt (Credit
cards, medical bills, other
debts)
Supreme Court of Ohio
Uniform Domestic Relations Form — Affidavit 2
AFFIDAVIT OF PROPERTY AND DEBT
Approved under Ohio Civil Rule 84
Amended: XXXX, 2021 Page4 of 5
Type Name of Creditor Name on Total Debt Monthly
Account Due Payment
$ $
$ $
TOTAL SECTION IV: DEBT: $
V. BANKRUPTCY
Filed by Date of Filing Date of Type of Case Current
Discharge or (Ch. 7, 11, 12, Monthly
Relief from 13) Payments
Stay
$ $
.
$ $
TOTAL SECTION V: BANKRUPTCY: $
OATH OR AFFIRMATION
(Do not sign until Notary Public is present)
I, (print name). 2 el , swear or affirm that | have read this Affidavit and, to the best
of my knowledge and belief, the facts and information stated in this Affidavit are true, accurate, and complete. |
understand that if | do not tell the truth, | may be subject to penalties for perjury.
en
Ve OFFS
Your Signature
STATE OF __Qhio )
)ss
COUNTY OF__ClOYK )
Sworn to or affirmed before me by. Amie Collett this_S* dayof Apri 20a.
SRA HES
8 Lanva.\ Hedges
ow Healgte—
Signature of Notary Public
yf ee
2
NOTARY PUBLIC
STATE OF OHIO
Laura Hedaes
oF Printed Name of Notary Public
My Commission Expire.
eA dune 14,2024
Commission Expiration Date: _(/ u/ay
Uniform Domestic Relations Form — Affidavit 2
AFFIDAVIT OF PROPERTY AND DEBT
Approved under Ohio Civil Rule 84
Amended: XXXX, 2021 Page 5 of 5
Preview
: : IN THE COURT OF COMMON PLEAS ommestic DIVISION Clark COUNTY, OHIO Amiee Collett Clark County, Ohio Case No. 240R13 Piaintiff/Petitioner 1 FILED Judge. vs./and APR 04 2024 Magistrate Dylan Lower Common Pleas Court Defendant/Petitioner 2 Melissa-M. Tuttle, Clerk Check tocal 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. You must provide the most recent value for each asset and balance owed for each debt. 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 PROP! ‘le DEBT Affidavit of Ce’ il ex I. REAL ESTATE INTERESTS Addres: Present Fair Titled To Mortgage Balance Eauity Market Value TOTAL SECTION I: REAL ESTATE INTERESTS: $§. ll. OTHER ASSETS Gategory Description A. Vehicles and Other Certificate (Include model and year of of Title Property automobiles, trucks, motorcycles, boats, motors, motor homes, trailers, ATVs, snowmobiles, jet skis, etc.) 1 2. Supreme Court of Ohio Page 1 of 5 Uniform Domestic Relations Form — Affidavit 2 AFFIDAVIT OF PROPERTY AND DEBT Approved under Ohio Civil Rule 84 Amended: June 1, 2021 B. Financial Accounts (Include checking, savings, CDs, POD accounts, money market accounts, etc.) Chase Coecthind, $28.92 . Sndst SQLS. ¢ OF. 94 C. Pensions & Retirement (Include profit-sharing, IRAs, Plans 401(k) plans, etc. Describe each type of plan) D. Publicly Held Stocks, (Name of company and number of Bonds, Securities & Mutual shares) Funds Supreme Court of Ohio Uniform Domestic Relations Form — Affidavit 2 AFFIDAVIT OF PROPERTY AND DEBT Approved under Ohio Civil Rule 84 Amended: XXXX, 2021 Page 2 of 5 Category Description E. Closely Held Stocks & Other (Type of ownership and number of Business Interests and Name shares) of Company $ $ F. Life Insurance (Company (Insured Life) Cash Value and Name and Term or Whole Life) Loan Balance, if any $ $ $ G. Furniture & Household Goods, Furnishings, and Appliances H. Safe Deposit Box (Give location and contents) 1. All Other Assets Not Listed (If necessary, attach additional Above (including jewelry, art, pages) tools, firearms, and other collectibles) $ $ TOTAL SECTION Ii: OTHER ASSETS: $ Supreme Court of Ohio Uniform Domestic Relations Form — Affidavit 2 AFFIDAVIT OF PROPERTY AND DEBT Approved under Ohio Civil Rule 84 Amended: XXXX, 2021 Page 3 of 5 Ill SEPARATE PROPERTY CLAIMS Separate property includes, but is not limited to, property owned before marriage and gifts or inheritances to only one spouse. Description Why do you claim Present Fair Market this as separate Value property? $ TOTAL SECTION Ill: SEPARATE PROPERTY CLAIMS: $ IV, DEBT List ALL OF YOUR DEBTS, your spouse's debts, 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. Type Name of Creditor Name on Total Debt Monthly Account Due Payment A. Secured Debt (Mortgages, Car, ete.) B. Unsecured Debt (Credit cards, medical bills, other debts) Supreme Court of Ohio Uniform Domestic Relations Form — Affidavit 2 AFFIDAVIT OF PROPERTY AND DEBT Approved under Ohio Civil Rule 84 Amended: XXXX, 2021 Page4 of 5 Type Name of Creditor Name on Total Debt Monthly Account Due Payment $ $ $ $ TOTAL SECTION IV: DEBT: $ V. BANKRUPTCY Filed by Date of Filing Date of Type of Case Current Discharge or (Ch. 7, 11, 12, Monthly Relief from 13) Payments Stay $ $ . $ $ TOTAL SECTION V: BANKRUPTCY: $ OATH OR AFFIRMATION (Do not sign until Notary Public is present) I, (print name). 2 el , swear or affirm that | have read this Affidavit and, to the best of my knowledge and belief, the facts and information stated in this Affidavit are true, accurate, and complete. | understand that if | do not tell the truth, | may be subject to penalties for perjury. en Ve OFFS Your Signature STATE OF __Qhio ) )ss COUNTY OF__ClOYK ) Sworn to or affirmed before me by. Amie Collett this_S* dayof Apri 20a. SRA HES 8 Lanva.\ Hedges ow Healgte— Signature of Notary Public yf ee 2 NOTARY PUBLIC STATE OF OHIO Laura Hedaes oF Printed Name of Notary Public My Commission Expire. eA dune 14,2024 Commission Expiration Date: _(/ u/ay Uniform Domestic Relations Form — Affidavit 2 AFFIDAVIT OF PROPERTY AND DEBT Approved under Ohio Civil Rule 84 Amended: XXXX, 2021 Page 5 of 5