PC-G-17.0A (Rev. 1-2001) PROBATE COURT OF FRANKLIN COUNTY, OHIO JUDGE ERIC BROWN LAWRENCE A. BELSKIS, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. APPLICATION FOR APPOINTMENT OF GUARDIAN OF INCOMPETENT [R.C.2111.03] Initial Appointment Successor Appointment Applicant alleges that is incompetent and is in need of a guardian. Applicant further states: Note: If the space allotted is inadequate to respond, write "See Exhibit" in the space and attach the exhibit containing the information requested. 1. TYPE OF GUARDIANSHIP FOR WHICH APPLICATION IS MADE: A. Non-Limited Limited Interim B. Person and Estate Estate Only Person Only Emergency 2. IF THE APPLICATION IS FOR A LIMITED GUARDIANSHIP: A. The requested length of time of the guardianship is: Indefinite Definite from 20 to B. The limited powers requested to be granted to the guardian are: 20 3. IF THE APPLICATION IS FOR A GUARDIANSHIP OF THE ESTATE: A. The whole estate of the prospective ward is: Probable Value Personal Property ...................................................................................... $ Real Property ................................................................................................. Annual Rents and income from every source ............................................... Other ................................. TOTAL $ B. A bond in the amount of $ is attached or will be filed. 4. A LIST OF THE NEXT OF KIN, FORM 15.0, OF THE ALLEGED INCOMPETENT IS ATTACHED. FRANKLIN COUNTY FORM 17.0A - APPLICATION FOR APPOINTMENT OF GUARDIAN OF INCOMPETENT American LegalNet, Inc. www.FormsWorkflow.com CASE NO. 5. INFORMATION CONCERNING THE PROSPECTIVE GUARDIAN / APPLICANT: A. Name and AKA Home Address City, State, Zip Code Telephone Number: Home Work D.O.B. Relationship to Alleged Incompetent Do you currently act as any of the following for the proposed ward? Physician Attorney Landlord Caregiver Custodian Creditor Power of Attorney Durable Power of Attorney for Health Care Occupation Work Address City, State, Zip Code B. Applicant (is/is not) an administrator, executor, or other fiduciary of an estate wherein the prospective ward has an interest, O.R.C. 2111.09. C. Applicant (has/has not) been charged with, or convicted of, a crime involving theft; physical violence; or sexual, alcohol, or substance abuse. If the Applicant has been so charged or convicted, list dates and places of the charge(s) or conviction(s), O.R.C. 2111.03(A). Charge/Conviction Date Place 6. INFORMATION CONCERNING THE ALLEGED INCOMPETENT: A. Full Name and AKA Age Date of Birth Male Female Legal settlement or residence City, State, Zip Code in County, Ohio Telephone Number Length of time at that residence B. If the alleged incompetent is living at an address different from the residence shown in Section 6-A above, list that address. C. Name of person, other than alleged incompetent, who may be contacted at the address where the alleged incompetent is living. Telephone Number Best time to call 2 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. D. In the event of the death or incapacity of the applicant/guardian, the Court should contact the nearest friends or relatives whose names and addresses are: Telephone Number Name Address City, State, Zip Code Name Telephone Number Address City, State, Zip Code Name Telephone Number Address City, State, Zip Code 7. FURTHER INFORMATION CONCERNING THE ALLEGED INCOMPETENT: A. The present guardian is: (if "none" so state) Name Address Are any of the following less intrusive measures in place? Living will Durable power of attorney Power of attorney Limited guardianship Conservatorship Representative payee Health care durable power of attorney B. Describe the prospective ward's alleged mental and/or physical incompetency. C. The applicant believes the proposed ward should retain the following rights, if any: None Vote Marry Contract Execute a will Obtain driver's license / drive a vehicle Hold or convey property Other: (please specify) D. A Statement of Expert Evaluation, Form 17.1A, is attached. E. Indicate names of any/all physicians and other related professionals who have treated or counseled the prospective ward within the last 2 years. 3 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. F. To the best of your ability, list prescriptions and/or over the counter medication taken by the prospective ward. G. List any problems the alleged incompetent may have in communicating. H. List all agencies, public or private, who have knowledge of the alleged incompetent which may be of assistance in determining the need for the guardianship. Indicate the contact person at the agencies. I. If applicant is considering protective placement, complete the following: a. The proposed ward suffers from the following disabilities: Infirmities of aging Chronic mental illness Developmentally disabled Substance Abuse b. The proposed ward has a primary need for residential care and custody because: c. The proposed ward is totally incapable of providing for her/his own care or custody so as to create a substantial risk of serious harm to herself/himself for others. 1. The anticipated least restrictive placement for the proposed ward is: 2. An unlocked unit A locked unit is most appropriate. I hereby apply to the court to be appointed guardian of the above alleged incompetent person and certify that all the information and statements with this application and attached documents are correct to the best of my knowledge and belief. Signature Signature Attorney for Applicant and registration number Applicant Address Address City, State, Zip Code City, State, Zip Code ( Telephone ) ( Telephone 4 ) American LegalNet, Inc. www.FormsWorkflow.com