PC-A-18.PP1 (Rev. 6-2015) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE PLACEMENT OF CASE NO. PREPLACEMENT APPLICATION AND AFFIDAVIT STATE OF OHIO, FRANKLIN COUNTY, SS: The undersigned, being duly sworn, states that the following information and allegations are true to the best knowledge and belief: APPLICANT 1: First Middle Last Birth Date: Citizenship: Hair Color: Birthplace: Racial Descent: Eyes: Height: Religion Weight Education (High School and Other): Occupation: Employer's name, address and phone: Time Employed: Salary Previous marriages (spouse's name, marriage place and date, how, when and where terminated): APPLICANT 2: First Middle Last Birth Date: Citizenship: Hair Color: Birthplace: Racial Descent: Eyes: Height: Religion Weight Education (High School and Other): Occupation: Time Employed: Salary American LegalNet, Inc. www.FormsWorkFlow.com FRANKLIN COUNTY FORM 18.PP1 - PREPLACEMENT APPLICANT AND AFFIDAVIT (PAGE 1) CASE NO. Employer's name, address and phone: Previous marriages (spouse's name, marriage place and date, how, when and where terminated): APPLICANT 1 and/or APPLICANT 2 Address: City: Present Marriage: Directions to house Date Telephone: County: Place State: Zip: Ceremony Type Assets: Rent Own Mortgage/Rent Monthly $ Face Value $ Home-owner's Insurance Life, hospital, medical or other Insurance (include company and value): Investments (stocks and bonds, etc., include company and value): Names of children born to or adopted by either Applicant at any time: Name Of what marriage Present age Residing with whom FRANKLIN COUNTY FORM 18.PP1 - PREPLACEMENT APPLICANT AND AFFIDAVIT (PAGE 2) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. Names of other members of household including employees: Name Age Occupation Relationship Non-Relative references who know you both well - list five (i.e. clergyman, physician): Name 1. 2. 3. 4. 5. Have either of you ever applied to adopt a child from any source previously? If so, with whom, when and where: Yes No Address Telephone Disposition? Have either of you applied for a divorce or sought marital counseling in the last three (3) years? Yes No Have any of you ever been arrested for or convicted of any criminal offense other than minor traffic violations? Yes No If yes, give details: Have either of you ever been confined in a mental institution, psychiatric ward or under the care of a psychiatrist? Yes No If yes, give name, address and telephone number of therapist and details of treatment: FRANKLIN COUNTY FORM 18.PP1 - PREPLACEMENT APPLICANT AND AFFIDAVIT (PAGE 3) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. Wherefore, your Applicant(s) pray that the Court make an investigation concerning themselves and the information contained in this Application, for which authority is hereby expressly given, and to approve them as proposed adopting parents for placement of a child by virtue of Section 5103.16, Ohio Revised Code. Applicant 1 Applicant 2 Sworn to and subscribed before me a Notary Public or Deputy Clerk of the Probate Court on this , 20 . day of Notary Public/Deputy Clerk Attorney for Applicant(s) Typed or Printed Name Address City, State, Zip Code Telephone Number (include area code) Attorney's Registration No. FRANKLIN COUNTY FORM 18.PP1 - PREPLACEMENT APPLICANT AND AFFIDAVIT (PAGE 4) American LegalNet, Inc. www.FormsWorkFlow.com