PROBATE COURT OF BUTLER COUNTY, OHIO RANDY T. ROGERS, JUDGE IN THE MATTER OF: , AN ADULT CASE NO. PETITION FOR EMERGENCY PROTECTIVE SERVICES [R.C. 5101.69] 1. Petitioner, , is an authorized provider of adult protective Services pursuant to R.C. 5101.60, et seq. and has received a report that the above named Adult is in need of protective services. 2. The Adult, , residing at is years of age, with a date of birth of , is alleged to be an incapacitated person and an emergency exists. 3. The specific facts alleging the nature of the emergency are: 4. The proposed emergency protective services including placement, if applicable, are: 5. The Adult and the following persons are required to receive notice 24 hours prior to the hearing pursuant to R.C. 5101.69: Name Address Relationship to Adult FORM 23.2 - PETITION FOR EMERGENCY PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 6. (Complete if applicable) Petition requests a waiver of the 24 hour notice requirement because: a.) Immediate and irreparable physical harm to the Adult or others will result from the 24 hour delay. Explain: and b.) Reasonable attempts have been made to notify the above listed individuals, if any, if their whereabouts are known. Explain: 7. The Adult has not consented and there is no person authorized by law or court order available or willing to give consent to the emergency protective services. WHEREFORE, the Petitioner requests the Court to authorize the implementation of the proposed emergency protective services and for such other relief as may be equitable. Butler County Department of Job & Family Services By: Attorney Address Title Address Phone Number (including area code) Registration No. Phone Number (including area code) E-mail E-mail FORM 23.2 - PETITION FOR EMERGENCY PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com