PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF THE CONSERVATORSHIP OF CASE NO. APPLICATION FOR APPOINTMENT OF CONSERVATOR (R.C. 2111.021) I, , Petitioner, hereby state that I am a competent adult but am physically infirm. I request that: 1. Name of Proposed Conservator Street City , Ohio (Zip) be appointed conservator of my: [ ] Person and Estate [ Telephone ] Person Only 2. The length (time period) of the conservatorship is: [ ] Indefinite [ ] Definite - to the [ ] Estate Only day of , 3. (If "Person Only" or "Person and Estate" is checked), I give the following power over my PERSON to the: a. Conservator: [ ] (1) All powers that a guardian would have under the guardianship laws of Ohio. [ ] (2) Limited to the power to b. Court: [ ] (1) All powers that a Court would have under the guardianship laws of Ohio. [ ] (2) Limited to the power to 4. (If "Estate Only" or "Person and Estate" is checked), I give the following power over my ESTATE to the: a. Conservator: [ ] (1) All powers that a guardian would have under the guardianship laws of Ohio. [ ] (2) Limited to the power to American LegalNet, Inc. www.USCourtForms.com FORM 20.0. - APPLICATION FOR APPOINTMENT OF CONSERVATOR - PDF - PAGE 1 4-1-2004 CASE NO._____________________ b. Court: [ ] (1) All powers that a Court would have under the guardianship laws of Ohio. [ ] (2) Limited to the power to c. The following of my property is subject to the foregoing powers: [ ] (1) All property. (attach description of property) [ ] (2) Only the property listed as follows: 5. If the application is for a conservatorship of the estate: a. The estate to be placed under conservatorship is: Personal Property $ Real Property $ Annual Rents $ Other Annual Income $ TOTAL b. A bond in the amount of $ $ is attached. (R.C. 2109.04(A)(1)) (Form 15.3) 6. Service of notice of the conservatorship is to be given to: [ ] None [ ] Same as Guardianship [ ] As Listed on Form 15.0 Based on the foregoing information, I do hereby petition the Court to appoint a Conservator for myself, and do so freely and of my own will. I certify that all information and statements contained in this application and the attached exhibits are correct to the best of my knowledge and belief. Date Attorney’s Signature Applicant's Signature (Type or print Attorney's Name) (Type or print Applicant’s Name) (Street) (Street) (City, State, Zip Code) (City, State, Zip Code) (Telephone Number--Include Area Code) (Telephone Number--Include Area Code) Supreme Court Registration Number American LegalNet, Inc. www.USCourtForms.com FORM 20.0. - APPLICATION FOR APPOINTMENT OF CONSERVATOR - PDF - PAGE 2 4-1-2004