PROBATE COURT OF BUTLER COUNTY, OHIO ADOPTION OF (Name after adoption) CASE NO. PETITIONER'S ACCOUNT [R.C. 3107.055] PRELIMINARY ESTIMATE ACCOUNTING (To be filed not later than date petition filed) FINAL ACCOUNTING (To be filed not later than 10 days prior to date of final hearing) This accounting specifies all disbursements of anything of value the Petitioner, a person on the Petitioner's behalf, and the agency or attorney made and has agreed to make in connection with the minor's permanent surrender under Division (B) of Section 5103.15 of the Revised Code, placement under Section 5103.16 of the Revised Code, and adoption under Chapter 3107. (Attach extra sheets if necessary) DATE NAME AND ADDRESS DISBURSEMENTS MADE OR AGREED TO BE MADE ACTUAL COSTS PHYSICIAN HOSPITAL/MEDICAL FACILITY ATTORNEY ACTUAL COST TO THE ATTORNEY AGENCY ACTUAL COST TO THE AGENCY MAINTENANCE & MEDICAL CARE REQ'D UNDER R.C. 5103.15 EXPENSES PURSUANT TO R.C. 3107.055(C)(9) FOSTER CARE GUARDIAN AD LITEM BUTLER COUNTY PROBATE COURT COSTS ALL OTHER DISBURSEMENTS TOTAL FORM 18.9 - PETITIONER'S ACCOUNT 09/01/2011 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. [Reverse of Form 18.9] CERTIFICATION OF PETITIONER'S ACCOUNT The undersigned certifies this _____ day of ____________, _______, that this accounting is true and accurate. Attorney or Agency (Signature) Typed or Printed Name Address City State Telephone Number (include area code) The Petitioner has reviewed this accounting and attests to its accuracy this _____ day of ____________, _______. Petitioner Petitioner FORM 18.9 - PETITIONER'S ACCOUNT PAGE 2 09/01/2011 American LegalNet, Inc. www.FormsWorkFlow.com