MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO IN THE MATTER OF _____________________________________________________________________ CASE NO. __________________ DOCKET __________________________ PAGE ___________________ APPLICATION FOR APPOINTMENT OF CONSERVATOR [R.C. 2111.021] I, ____________________________________, Petitioner, hereby state that I am a competent adult but am physically infirm. I request that: 1. Name of Proposed Conservator____________________________________________________ Street_________________________________________________________________________ City______________________, Ohio (Zip)____________Telephone(____)_________________ be appointed conservator of my: [ ] Person and Estate [ ] Person Only [ ] Estate Only The length (time period) of the conservatorship is: [ ] Indefinite [ ] Definite-to_____________________________20_____ (If "Person Only" or "Person and Estate" is checked), I give the following power over my PERSON to the: a. Conservator [ ] (1) All powers that a guardian would have under the guardianship laws of Ohio. [ ] (2) Limited to the power to__________________________________________________ ________________________________________________________________________ b. Court [ ] (1) All powers that a Court would have under the guardianship laws of Ohio. [ ] (2) Limited to the powers to__________________________________________________ ________________________________________________________________________ (If "Estate Only" or "Person and Estate" is checked), I give the following power over my ESTATE to the: a. Conservator [ ] (1) All powers that a guardian would have under the guardianship laws of Ohio. [ ] (2) Limited to the power to__________________________________________________ ________________________________________________________________________ b. Court [ ] (1) All powers that a Court would have under the guardianship laws of Ohio. [ ] (2) Limited to the powers to__________________________________________________ ________________________________________________________________________ c. The following of my property is subject to the foregoing powers: [ ] (1) All property. (attach description of property) [ ] (2) Only the property listed as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ FORM 20.0-APPLICATION FOR APPOINTMENT OF CONSERVATOR American LegalNet, Inc. www.FormsWorkFlow.com 2. 3. 4. [Side 2 of FORM 20.0] 5. If the application is for a conservatorship of the estate: a. The estate to be placed under conservatorship is: Personal Property $________________ Real Property $________________ Annual Rents $________________ Other Annual Income $________________ 0.00 Total $________________ b. A bond in the amount of $_________________is attached. (R.C. 2109.04(A)(1))(Form 15.3) Service of notice of the conservatorship is to be given to: [ ] None [ ] Same as Guardianship 6. [ ] As Listed on Form 15.0 Based on the foregoing information, I do hereby petition the Court to appoint a Conservator for myself, and do so freely and of my own will. I certify that all information and statements contained in this application and the attached exhibits are correct to the best of my knowledge and belief. __________________________________ Date __________________________________ Applicant's Signature __________________________________ Applicant's Typed or Printed Name __________________________________ Street Address __________________________________ City State Zip Code __________________________________ Phone Number (include area code) __________________________________ Attorney for Applicant __________________________________ Typed or Printed Name __________________________________ Street Address __________________________________ City State Zip Code __________________________________ Phone Number (include area code) Attorney Registration No._____________ Print Reset American LegalNet, Inc. www.FormsWorkFlow.com