PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF GUARDIANSHIP OF Case No. APPLICATION FOR APPOINTMENT OF EMERGENCY GUARDIAN OF ALLEGED INCOMPETENT [R.C. 2111.02] Applicant represents to the Court that aged years, resides or has a legal settlement at , in County, Ohio and that the prospective ward is incompetent by reason of (R.C. 2111.01(D)) . Applicant further represents that an emergency exists and that it is reasonably certain that immediate action is required to prevent significant injury to the person or estate of the proposed ward. A Statement of Expert Evaluation is attached. (Form 17.1) A List of Next of Kin of the Proposed W ard is also Attached (Form 15.0), however, applicant requests that the Court act ex parte, without notice because of the emergency existing. The whole estate of the prospective ward is estimated as follows: Personal property........................................................ $ Real estate................................................................... $ Applicant represents that he/she/they is/are not an administrator, executor or other fiduciary of the estate wherein the alleged incompetent is interested. Applicant further represents that a guardian of the alleged incompetent is necessary in order that the ward ward's property may be taken proper care of and asks that a guardian be appointed. PRESENT LOCATION OF WARD: Street City, State, Zip Code TYPE OF GUARDIANSHIP APPLIED FOR IS EMERGENCY limited person and estate estate only person only The limited powers requested are The time period requested is from to Applicant's relationship to alleged incompetent is BCPC FORM 504 - APPLICATION FOR APPOINTMENT OF EMERGENCY GUARDIAN OF ALLEGED INCOMPETENT - PDF - Page 1 . . 4/1/04 American LegalNet, Inc. www.FormsWorkflow.com Case No. The Applicant has (not) been charged with or convicted of a crime involving theft, physical violence, or sexual, alcohol or substance abuse except as follows (if applicable, state date and place of each charge or each conviction): . Attorney for Applicant Applicant 1 Type or Print name Type or Print name Address Age City, State, Zip Code Address Phone number (include area code) City, State, Zip Code Supreme Court Registration Number Phone number (include area code) Applicant 2 Type or Print name Age Address City, State, Zip Code Phone number (include area code) KNOW INGLY GIVING FALSE INFORM ATION ON A PROBATE DOCUMENT IS A CRIMINAL OFFENSE. [R.C. 2921.13 (A)(11)] BCPC FORM 504 - APPLICATION FOR APPOINTMENT OF EMERGENCY GUARDIAN OF ALLEGED INCOMPETENT - PDF - Page 2 4/1/04 American LegalNet, Inc. www.FormsWorkflow.com