PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE LAWRENCE A. BELSKIS, JUDGE PC-C-20.0A ( REV. 3/2001) IN THE MATTER OF THE CONSERVATORSHIP OF CASE NO. PETITION FOR APPOINTMENT OF A CONSERVATOR [R.C. 2111.021] The Petitioner states that he/she is a competent adult who is physically infirm and petitions the Court to appoint as his/her Conservator. Petitioner further states the following: [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 Conservatorship for Which Petition is Made: A. B. Non-Limited Person & Estate Limited Estate Only Person Only 2. If the Petition is for a Limited Conservatorship A. The length (time period) of the conservatorship requested is: (1) (2) Indefinite Definite from to B. The limited powers granted to the Conservator are: 20 20 3. If the Petition is for a Conservatorship of the Estate: A. The whole estate of the petitioner is: Personal Property ................................................................................... $ Real Property .......................................................................................... $ Annual Rents ........................................................................................... $ Other Income .......................................................................................... $ TOTAL $ FRANKLIN COUNTY FORM 20.0A PETITION FOR THE APPOINTMENT OF A CONSERVATOR American LegalNet, Inc. www.FormsWorkFlow.com Case No. B. A schedule describing with particularity all property within the scope of this Conservatorship is attached . [Attach Form 20.0D] C. A bond in the amount of $ attached. [Attach Form 20.0B] 5. Information Concerning the Prospective Conservator. A. Name and AKA Home Address Zip Relationship to Petitioner Occupation Work Address Zip Telephone D.O.B. B. Conservator (is/is not) an administrator, executor, or other fiduciary of the estate wherein the Petitioner has an interest. (R.C. 2111.09) C. Conservator (has/has not) been charged with, or convicted of, a crime involving theft; physical violence; or sexual, alcohol, or substance abuse. If the Conservator has been so charged or convicted, list dates and places of the charge(s) or conviction(s), (R.C. 2111.03(A)): Charge/Conviction Date Place Home Work is attached. [Attach Form 20.0E] 4. List of Next of Kin of the Petitioner, for Service of Notice and/or Waiver(s), if any, are 6. Information Concerning the Petitioner: A. Full Name and AKA Age Date of Birth Male Female Legal settlement or residence is: in Length of time at that residence is above, that address is: County, Ohio. B. If the petitioner is living at an address different from the residence shown in Section 6-A 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No. C. Name of person, other than the petitioner, who may be contacted at the address where the petitioner is living: Name Telephone D. In the event of the death or incapacity of the conservator, the Court should contact the nearest friends or relatives whose names and addresses are: Name Telephone Address Zip Name Telephone Address Zip Name Address Zip 7. Information Concerning the Petitioner: A. Describe the basis for the petitioners alleged infirmity: Telephone I hereby petition the court to have appointed as my Conservator and certify that all the information and statements contained in this petition and attached exhibits are correct to the best of my knowledge and belief. Signature Attorney for Petitioner Address City, State, Zip Code Telephone Signature Petitioner Address City, State, Zip Code Telephone 3 American LegalNet, Inc. www.FormsWorkFlow.com