PC-MI-50.6B (Rev. 5-2007) PROBATE COURT OF FRANKLIN COUNTY, OHIO JUDGE A. BELSKIS, JUDGE LAWRENCE ALAN S. ACKER IN THE MATTER OF CASE NO. AFFIDAVIT OF MENTAL RETARDATION The State of Ohio, Franklin County s.s. , [R.C.5123.71] the undersigned, residing at says that they have information or actual knowledge to believe that the respondent is a person with mental retardation who resides or is institutionalized at , Franklin County, Ohio, and that the person is subject to involunt ry institutionalization by court order pursuant to R.C. 5123.71 as defined a , by R.C. 5123.01(L). This allegation is that the above respondentis a: “Mentally retarded peron subject to institutionalization by court order” who is a person age eighteen or older, is a least moderately menatlly retarded and, because of their retardation, the following condition(s) exist: (1) The person represents a very substantial of physical impairment or injury to himself as manifested by evidence that he is unable to provide for and is not providing for his most basic physical needs and that provision for such needs is not available in the community; (2) The person needs and is susceptible to significant habilitation in an institution. In addition, affiant provides the following factual grounds for the belief that the respondent is subject to institutinalization by court order Attached hereto is either a comprehensive evaluation report including a statement by the evaluation team tha they have performed a comprehensive examination of the person and that they are of the opinion that hte peron has mental retardation and is subject to institutionalization by court order, or a written and sworn statement that the person or that the guardian of a minor or adjudicated incompetent person has refused to allow a comprehensive evaluation. FRANKLIN COUNTY FORM 50.6B - AFFIDAVIT OF MENTAL ILLNESS American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. The name and address of respondent’s legal guardian, if any, is: The identification of the adult next of kin of the repondent follows: NAME ADDRESS KINSHIP AGE That the following constitutes additional information that may be necessary for the purpose of determining residence: Dated this day of , 20 . Affiant Sworn to before me and signed in my presence on the day and year above dated. JUDGE/MAGISTRATE Franklin County Probate Court WAIVER I, the undersigned affiant, hereby waive the issuing and service of Notice of the Hearing on this Affidavit, and voluntarily enter my appearance herein. Date Affiant American LegalNet, Inc. www.FormsWorkFlow.com