COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.STATE OF OHIOIN THE COMMON PLEAS COURT COUNTY OF CUYAHOGAJUVENILE COURT DIVISIONCalendar No.IN THE MATTER OF:CASE NUMBER:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)DATE OF BIRTH:BELIEVED TO BE A DEPENDENT CHILDCOMPLAINT IN DEPENDENCYbeing first duly sworn, says that,a child of about the age ofYears, is a DEPENDENT child as defined in Ohio Revised Code Section 2151.04(C).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .According to the attached medical certificate of a reputable practicing physician, the following medical and/or surgicaltreatment appears to be immediately necessary for said child:THE PEOPLE OF THE STATE OF NEW YORK TO.Said complainant alleges, based on information and belief, that reasonable efforts have been made to contact the parent(s) of said child in order to obtain consent to perform the above described treatment. Despite these efforts, the parent(s) cannot be located.Therefore, pursuant to Ohio Revised Code Section 2151.33 and Rule 13 of the Ohio Rules of Juvenile Procedure,complainant states that the interests and welfare of the child require that action be taken immediately; and requests that the Court proceed summarily and without notice and issue an immediate order permittingGREETINGS:toretain the child as a patient, and authorizing the performance of all medical and surgical procedures upon the child by the medical staff of said hospital that the doctors deem necessary for the child=s health and welfare, as more fully explained in the attached medical certificate.The parents of said child are: Father(name & address):WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room.Mother(name & address):.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.COMPLAINANTSTATE OF OHIO COUNTY OF CUYAHOGA, one of the Justices of theCourt in Witness, Honorableday of, 20 County,Sworn to before me and subscribed in my presence this., 20day of(Attorney must sign above and type name below)DEPUTY CLERK/NOTARY PUBLICAttorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com