PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF GUARDIANSHIP OF Case No. AUTHORIZATION FOR RELEASE OF INFORMATION I, of (address) do hereby authorize: (1) Adult Protective Services in Butler County and surrounding counties to release to the Butler County Probate Court, for an in camera inspection by the Court, any reports that may involve me that concern allegations of abuse, neglect, or the exploitation of an adult, (2) Butler County Sheriff and surrounding counties and municipalities to release to the Butler County Probate Court copies of any records of arrest and/or conviction concerning any criminal charges that I may have, and (3) Butler County Probate Court to obtain from Ohio Courts Network (OCN) current and previous residences, civil and criminal history records, driving records, birth records, public records or any criminal justice agency records that I may have in any federal, state, county, and municipal jurisdictions. Date of Birth Social Security Number Drivers License Number/State Issued Marital Status Previous Address Maiden Name Spouse's Name Name of Former Spouse(s) Name(s) of Child(ren) A.K.A. Signature Witness TO BE COMPLETED BY EACH AGENCY (Please check appropriate space and sign. If a record is located, attach record/information to this form.) Record Located No Record Located Adult Protective Services Record Located No Record Located Sheriff's Department Record Located No Record Located Ohio Courts Network (OCN) BCPC FORM 500G - AUTHORIZATION FOR RELEASE OF INFORMATION - GUARDIANSHIP - PDF Eff 09-16-2013 American LegalNet, Inc. www.FormsWorkFlow.com