PROBATE COURT OF LUCAS COUNTY, OHIO JUDGE JACK R. PUFFENBERGER IN THE MATTER OF THE ADOPTION OF CASE NO. APPLICATION FOR PLACEMENT BY RELATIVE(S) [R.C. 5103.16] Applicant(s) reside at __________________________________________ in _________________ County, and are related to the above child as the (paternal/maternal) ____________________________. The child was born at ___________________________ Hospital at ________ o'clock __.m. on the ____ day of ____________________, 20___. Applicant(s) state that the birth parents are _______________________ and _______________________ and are either deceased or have abandoned the child as determined under Section 3107.07(A) of the Ohio Revised Code. Applicant(s) request the Court to place captioned child with them for purposes of adoption. Applicant(s) further state that this placement will be in the best interest of the child. Wherefore, said relative(s) ask(s) the Court to set a hearing on said proposed placement, and that said placement be approved in accordance with the provisions of law. Date Applicant Applicant ______________________________ Attorney Name ______________________________ Address ______________________________ ______________________________ Phone Number LCPC FORM 20. 3-B American LegalNet, Inc. www.FormsWorkFlow.com