PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the PLACEMENT of:___________________________________________________________ (Child's Name After Adoption) Case No: ______________________ Date:__________________________ APPLICATION FOR INDEPENDENT HOME STUDY [R.C. 5103.16(D)(2), 3107.031,] Now comes Petitioner(s), _____________________________________________________________, and request(s) that the Court appoint an assessor to perform the services required to be performed by an assessor as set forth in Chapter 3107 and/or Chapter 5103 of the Revised Code. Petitioner(s) request(s) that the Court appoint _____________________________________________ as the assessor in this case and represents to the Court that said person or agency is duly licensed as an assessor in accordance with the requirements of Section 3107.012 of the Revised Code. Petitioner(s) understand(s) that the cost of the assessor services will be the sole responsibility of the Petitioner(s) and will contract directly with the assessor regarding payment for such services, subject to the provisions of Section 3107.10 or the Revised Code. Attorney for Petitioner Petitioner Typed or Printed Name Typed or Printed Name Street Address Petitioner City State Zip Code Typed or Printed Name Phone Number (include area code) Street Address Attorney Registration No. ___________________________ City State Zip Code Phone Number (include area code) FORM 18.1A - APPLICATION FOR INDEPENDENT HOME STUDY Crensch$\forms \18.1A.doc 181a 3/23/01 American LegalNet, Inc. www.USCourtForms.com