PC-MI-50.20A (02-2012)PROBATE COURT OF FRANKLIN COUNTY, OHIOROBERT G. MONTGOMERY, JUDGEIN RE:Case No.: MI-RespondentCERTIFICATE OF EXAMINATIONTVBH-CCPatient222s NamePatient222s Address2200 W. Broad St.Age Sex RaceColumbus Franklin OH43223Date of birthPlace of birthCity County StateZip CodeThe undersigned certifies that he / she is a licensed, in the State of Ohio, and that thefollowing are facts relating to the examination of the above named patient.I further certify that I have, with care and diligence, personally observed and examined the named patient on the dayof, 20 .That said patient was examined at, and as a result of suchexamination, I believe said patient is / is not in need ofas requested byfor reasons outlined below.REMARKS: Please indicate the condition needing attention and the most desirable method of treatment:Examiner222s SignaturePrinted NameAddressm36FRANKLIN COUNTY FORM 50.20A - CERTIFICATE OF EXAMINATION (TVBH-CC) American LegalNet, Inc. www.FormsWorkFlow.com