PC-G-17.0A (Rev. 2-2016) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT [R.C.2111.03] Successor Appointment resides or has a legal Initial Appointment Applicant represents to the court that settlement at in FRANKLIN County, Ohio and that the prospective ward is incompetent by reason of (R.C. 2111.01 (D)) and is in need of a guardian. The proposed ward's date of birth is 1. A Statement of Expert Evaluation is attached. (Form 17.1A) 2. A list of Next of Kin of Proposed Ward is also attached. (Form 15.0) 3. The whole estate of the prospective ward is estimated as follows: Personal Property..................... $ Real Estate .............................. $ Annual Rents............................ $ Other anual income .................. $ 4. Is the alleged incompetent the beneficiary of a special needs trust? Yes No . 5. Applicant represents that the applicant is not an administrator, executor or other fiduciary of the estate wherein the alleged incompetent is interested. 6. Applicant offers bond in the amount of $ is attached. will be filed. the ward 7. Applicant further represents that a guardian of the alleged incompetent is necessary in order that the ward's property may be taken proper care of and asks that a guardian be appointed. 8. TYPE OF GUARDIANSHIP APPLIED FOR IS: (Check the applicable boxes) Non-Limited Person and Estate 17.0 Limited Estate Only Interim Person Only Emergency FRANKLIN COUNTY FORM G-17.0A - APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT (PAGE 1) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 9. If limited guardianship is applied for, the limited powers requested are: The time period requested is indefinite definite to The applicant's relationship to the alleged incompetent is 10. INFORMATION CONCERNING THE PROSPECTIVE GUARDIAN / APPLICANT: A. Name and AKA Home Address City, State, Zip Code Telephone Number: D.O.B. Home Work Relationship to Alleged Incompetent Do you currently act as any of the following for the proposed ward? Physician Creditor Occupation Work Address City, Sate, Zip Code B. Applicant is is not an administrator, executor, or other fiduciary of an estate wherein the prospective Attorney Power of Attorney Landlord Caregiver Custodian Durable Power of Attorney for Health Care 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 17.0 FRANKLIN COUNTY FORM G-17.0A - APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT (PAGE 2) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 11. INFORMATION CONCERNING THE ALLEGED INCOMPETENT: A. Full Name and AKA Male Female Legal settlement or residence City, State, Zip Code in 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. County, Ohio Telephone Number 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 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: Name Address City, State, Zip Code Telephone Number Name Address City, State, Zip Code Telephone Number Name Address City, State, Zip Code 17.0 Telephone Number FRANKLIN COUNTY FORM G-17.0A - APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT (PAGE 3) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 12. 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 Limited guardianship Health care durable power of attorney B. Describe the prospective ward's alleged mental and/or physical incompetency. Durable power of attorney Conservatorship Power of attorney Representative payee C. The applicant believes the proposed ward should retain the following rights, if any: None Vote Marry Contract Execute a will Hold or convey property Obtain driver's license / drive a vehicle Other: (please specify) D. Indicate names of any/all physicians and other related professionals who have treated or counseled the prospective ward within the last 2 years. 17.0 FRANKLIN COUNTY FORM G-17.0A - APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT (PAGE 4) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. E. To the best of your ability, list prescriptions and/or over the counter medication taken by the prospective ward. F. List any problems the alleged incompetent may have in communicating. G. 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. H. 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 17.0 FRANKLIN COUNTY FORM G-17.0A - APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT (PAGE 5) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. The Applicant represents that a guardian has been nominated in a writing pursuant to R.C. 1337.09 (D) or R.C. 2111.121. The nominated person is: The nominated person's contact information is listed on Form 15.0 (Next of Kin). A copy of the document which nominates the guardian is attached, The Applicant represents that the proposed ward had military service. Military I.D.: Dates of service: Branch of service: Applicant represents that the address provided is the applicant's permanent address and acknowledge