PC-C-20.0J (Rev. 3/2001) PROBATE COURT OF FRANKLIN COUNTY, OHIO LAWRENCE A. BELSKIS, JUDGE ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE CONSERVATORSHIP OF CASE NO. STATEMENT OF EXPERT EVALUATION FOR CONSERVATORSHIP Ohio R.C. 2111.021 specifies that A competent adult who is physically infirm may petition the probate court***to place, for a definite or indefinite period of time, his person, any or all of his real or personal property, or both under a conservatorship***[A] petitioner either may grant specific powers to the conservator or court or may limit any powers granted by law*** This Statement of Expert Evaluation is intended to confirm mental competency with physical infirmity of the petitioner and is evidence to be considered by the Probate Court. The fee for completing this Statement WILL NOT be paid by the Probate Court. Each evaluator should secure payment from the Petitioner. I. A. B. This Statement of Expert Evaluation is completed for: (Check One) The initial Conservatorship Petition is to be completed by a physician and/or clinical psychologist, and attached to the Petition for Conservatorship as an Exhibit. Conservators Report. This evaluation can be completed by a physician, clinical psychologist, licensed clinical social worker, or mental retardation team. The Conservator must have this evaluation completed within three (3) months prior to filing the Conservators Report. 2. This Statement of Expert Evaluation is being completed by: Name Address Physician Licensed Clinical Social Worker Telephone Clinical Psychologist Mental Retardation Team 3. The following is my/our assessment of the physical capacity and functioning level of the patient/petitioner. FRANKLIN COUNTY FORM 20.0J - STATEMENT OF EXPERT EVALUATION FOR CONSERVATORSHIP American LegalNet, Inc. www.FormsWorkFlow.com Case No. 4. Is the petitioner mentally competent? Comments Yes No 5. Is the petitioner physically impaired? If Yes, describe Yes Yes No No 6. Is there observed/reported evidence of physical infirmity? 7. If the petitioner is physically impaired, what is the cause? 8. Can the petitioner conduct business without the aid of a conservator? Yes No Comments 9. Can the petitioner properly care for himself/herself without the aid of a conservator? Yes No Comments ADDITIONAL COMMENTS I hereby certify that I/We have evaluated the petitioner on the for the purpose of a conservatorship. day of , 20 , Date Evaluator American LegalNet, Inc. www.FormsWorkFlow.com