PROBATE COURT OF BUTLER COUNTY, OHIO RANDY T. ROGERS, JUDGE , AN ADULT IN THE MATTER OF: CASE NO. NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES [R.C. 5101.66] TO: Name and Address of Adult Incapacitated Person Name Address Relationship of Adult Adult, Guardian, Legal Counsel, Caretaker, Spouse, if any, and if none of these to the Adult’s Children or Next of Kin You are hereby notified that on the day of , , the Butler County Department of Job & Family Services filed in this Court a Petition for Court Ordered Protective Services for the above named Adult for the following reason(s): . This Petition for Court Ordered Protective Services shall be heard in the Butler County Probate Court located at the Butler County Courthouse, 101 High Street, Second Floor Hamilton, Ohio on the day of , , at o’clock AM/PM The Adult has the right to legal counsel and if indigent, legal counsel will be appointed if requested. WITNESS my signature and seal of said Court, this day of , Probate Judge By: Deputy Clerk WAIVER OF NOTICE W e, the undersigned, whose relationship to the Adult is indicated, enter our appearance and waive notice and consent to the hearing. Name Relationship to the Adult FORM 23.1 - NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. State of Ohio, Butler County Probate Court I hereby certify that I caused a copy of the within notice to be mailed, by certified mail, to the last known address of at at Randy T. Rogers, Probate Judge By: Deputy Clerk RETURN Butler County, Ohio , Received this notice on the o’clock AM/PM and on the day of , , day of at , I served the same by delivering a true copy thereof personally to FEES Sheriff Service and return, 1 st name, $ Deputy Sheriff/Process Server Additional names, at $ Miles traveled, at $ Name $ Title Total $ FORM 23.1 - NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com