PROBATE COURT OF BUTLER COUNTY, OHIO RANDY T. ROGERS, JUDGE GUARDIANSHIP OF CASE NO. APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT [R.C. 2111.03] Applicant represents to the Court that settlement at in resides or has a legal County, Ohio and that the prospective ward is incompetent by reason of (R.C. 2111.01(D)) The proposed ward's date of birth is A Statement of Expert Evaluation is attached. (Form 17.1) A list of Next of Kin of Proposed Ward is also attached. (Form 15.0) The whole estate of the prospective ward is estimated as follows: Personal Property.....................$ Real Estate..............................$ Annual Rents............................$ Other annual income.................$ Applicant represents that the applicant is not an administrator, executor or other fiduciary of the estate wherein the alleged incompetent is interested. Applicant offers the attached bond in the amount of $ . 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. TYPE OF GUARDIANSHIP APPLIED FOR IS [check the applicable boxes] non-limited limited person and estate estate only person only If limited guardianship is applied for, the limited powers requested are FORM 17.0 ­ APPLICATION FOR APPOINTMENT OF GUARDIAN (AN ALLEGED INCOMPETENT) Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 17.0] CASE NO.______________ The time period requested is indefinite definite to . Applicant's relationship to alleged incompetent is 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.) The Applicant represents that a guardian has been nominated in a writing pursuant to R.C. 1337.09(D) or R.C. 2111.121. The nominated person is . The nominated person's contact information is listed on Form 15.0 (Next of Kin). A copy of the document which nominates the guardian is attached. The Applicant represents that the proposed ward had military service. Military I.D.: Branch of service: Dates of service: Applicant represents that the address provided is the applicant's permanent address and acknowledges the requirement that the court be notified of any change of address. Removal may result from a failure to comply with this requirement. Attorney for Applicant Typed or Printed Name Address City State Zip Applicant Typed or Printed Name Age Permanent Address City State Zip Telephone Number (include area code) Attorney Registration No. Telephone Number (include area code) FORM 17.0 ­ APPLICATION FOR APPOINTMENT OF GUARDIAN (AN ALLEGED INCOMPETENT) PAGE 2 Amended: January 1, 2013 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com