BOWLING GREEN MUNICIPAL COURT 711 S. Dunbridge Rd., P.O. Box 326 Bowling Green, OH 43402-0326 (419) 352-5263
In Re: __________________________________________ Debtor __________________________________________ Address __________________________________________ City/State/Zip Tel. Hm. _______________ Wk. _______________ Employer __________________________________ STATE OF OHIO, WOOD COUNTY, SS: The following is a full, accurate, and complete statement of the names of the unsecured creditors of the undersigned, their addresses, and amount due and owing to each: NAME 1. 2. 3. 4. 5. 6. ADDRESS ACCT # AMOUNT DUE No. ______________________________ STATEMENT AS TO CREDITORS Pay Period: ________________________
7.
8. 9. 10. 11. 12. 13. 14.
On _____/_____/_____ sworn to before me and subscribed in my presence (seal)
_________________________________________ Debtor _________________________________________ Clerk of Court Deputy Clerk Notary Public, Com. Exp. ___/___/___ Judge