PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the PLACEMENT of:___________________________________________________ (Child's name prior to adoption) Case No. _____________________________ Date:______________________ APPLICATION FOR APPROVAL OF PLACEMENT (R.C. 5103.16(D)) Now comes ________________________________________ and represents that she is the mother and sole parent of ______________________________________________ who was born on ______________________, _______, at __________________________________. The applicant further represents that she is ____________ years of age and her address is ___________________________________________ and her phone number is ________________. It is proposed by her to place the child in the home of ______________________________ and ________________________________ who are husband and wife and their address is __________________________________________________________ and their phone number is _________________ for the purpose of having them adopt the child. The applicant further represents that placement would be to the best interest of the child. The applicant requests that the Court order an independent home study of the proposed placement to be conducted as provided in Section 3107.031 of the Revised Code. The applicant consents to the proposed placement. The applicant is aware of the right to contest the decree adoption subject to the limitations set forth in Section 3107.16 of the Revised Code. The applicant requests that a hearing be set to allow the applicant to appear before the Court concerning the proposed placement. WHEREFORE, the applicant prays that such proposed placement be approved. _____________________________________ Signature of Parent KNOWINGLY GIVING FALSE INFORMATION ON A PROBATE DOCUMENT IS A CRIMINAL OFFENSE [R.C. 2921.13(A)] FORM 19.2 - APPLICATION FOR APPROVAL OF PLACEMENT Crensch$\forms\19.2 192 3/23/01 American LegalNet, Inc. www.USCourtForms.com