PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF THE PLACEMENT OF (Current name of child) CASE NO. APPLICATION BY PARENT FOR APPROVAL OF PLACEMENT [R.C. 5103.16(D)] Applicant, , who resides at (Full name of parent) represents that applicant is the (Address of parent) mother as established pursuant to R.C. 3111.02(A) father as established pursuant to R.C. 3111.02(A) of a child whose date of birth is . Applicant proposes that said child be placed for adoption and states that such proposed placement would be in the best interest of the child. 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. Applicant consents to the proposed placement. Applicant states that applicant is aware of his/her right to contest the decree of adoption subject to the limitations of section 3107.16 of the Revised Code. Applicant requests that a hearing be set to allow the Applicant to appear before the Court concerning the proposed placement. WHEREFORE, Applicant prays that such proposed placement be approved. Signature of Parent BCPC FORM 303 - APPLICATION BY PARENT FOR APPROVAL OF PLACEMENT 4/98 2001 © American LegalNet, Inc.