FRANKLIN COUNTY MUNICIPAL COURT
Lori M. Tyack, Clerk
Trusteeship Division
375 South High Street, 3
rd
Floor
Columbus, Ohio 43215
(614) 645-7420
www.fcmcclerk.com
TRUSTEESHIP CASE # __________ CVT _______________
NAME: __________________________________________________ SSN: __________________________
ADDRESS: ______________________________________________________________________________
CITY: _________________________________ STATE ___________________ ZIP CODE _____________
TELEPHONE; HOME (__)______________ WORK (___)_____________ CELL (___)_________________
EMAIL ADDRESS: ___________________________________________________________
APPLICATION FOR APPOINTMENT OF TRUSTEE
Now comes the Applicant, __________________________ and states that he/she is employed by
___________________________________ located at _____________________________________
and that personal earnings are $__________, (Weekly, Bi-Weekly, Semi Monthly, Monthly).
Applicant further states that a fifteen (15) day demand has been made upon him/her in
accordance with the ORC 2716.02 and requests the Court to appoint Lori M. Tyack, Trustee, to receive
that portion of his/her personal earnings not exempt from execution, attachment, or proceedings in aid of
execution, and such additional sums as he/she may voluntary pay or assign to the Trustee.
The applicant further states that he/she has not had a Trusteeship which was dismissed, for any
reason, within six (6) months from the date of filing this application.
Is the applicant head of household? Yes No
Does the applicant have dependants?
If so, applicant is required to list below:
Name Age Relationship
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Is the applicant being filed by an attorney? Yes No
If so, please indicate below:
Name:________________________Address:_____________________________________________
AttorneyCode:_________________AttorneyFee: ____________________________________________
*Please consult Rule #3 under rules and procedures for an explanation of attorney fee priority.
The following section requires the applicant to list the names of secured and unsecured creditors
with liquidated claims. If the account is being collected by a collection agency, attorney or other party,
please list the name and address of said collector as well. For further explanation, consult steps 4-7 of
the rules and procedures guide.
NOTE: When listing an account for the phone company, applicant must include the complete
phone number for the property when the bill was accrued. This is the account number for that
creditor.
___________________________________________________________________________________
Account # Creditor Complete Mailing address
________________________________________________________________$___________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
__________________________________________________________________________________
Account # Creditor Complete Mailing address
_______________________________________________________________ $__________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
______________________________________________________________ $____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
______________________________________________________________$_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
______________________________________________________________$ ____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
Total debt for this page $_______________
____________________________________________________________________________________
Account # Creditor Complete Mailing address
_____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
_____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
___________________________________________________________________________________
Account # Creditor Complete Mailing address
____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
Total debt for this page $_______________
____________________________________________________________________________________
Account # Creditor Complete Mailing address
_____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
_____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
____________________________________________________________________________________
Account # Creditor Complete Mailing address
____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
___________________________________________________________________________________
Account # Creditor Complete Mailing address
____________________________________________________________ $_____________________
Name on Account Complete Billing address Amount Owed
_________________________________________________________________ Secured Debt
Collection Agency Complete Mailing Address Unsecured Debt
Total debt for this page $_______________
TOTAL INDEBTEDNESS $ ______________________
Wherefore, petitioner asks the clerk of this court to be appointed as Trustee.
State of Ohio
Franklin County ss
________________________________________, being first duly cautioned and sworn, deposes and
says that he/she is the petitioner herein and that the facts stated and allegations contained in the
foregoing application are true as he/she verily believes.
__________________________________________
Applicant Signature
Sworn to before me and subscribed in my presence this ______ day of _____________________, ____.
___________________________________ __________________________________________
Attorney for Applicant Notary Public or Deputy Clerk
