MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO IN THE MATTER OF _______________________________________________________________________ Case No. ________________________________________ Docket ____________________ Page___________ APPLICATION FOR APPOINTMENT OF GUARDIAN (OF MINOR) Note: If allotted space is inadequate to respond, write "See Exhibit" in the space and add appropriate exhibit letter sequence, then attach exhibit containing information requested for that space. Applicant represents to the Court that the minor(s) listed is (are) in need of guardian (R.C. 2111.02), and the following: Name of Minor(s) Age Date of Birth Residence or Legal Settlement 1. TYPE OF GUARDIANSHIP APPLIED FOR: a. b. Non-Limited Person and Estate Limited Estate Only Person Only 2. REASONS FOR THE GUARDIANSHIP (R.C. 2111.06): _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 3. IF THE APPLICATION IS FOR A LIMITED GUARDIANSHIP, (R.C. 2111.02(B)(1)): a. The length (time period) of the guardianship requested is: Indefinite Definite � from _______________________________ 20__________ to _________________________________ 20__________ b. The limited powers granted to the guardian are: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ GUARDIANSHIP APPLICATION - MINOR (MINOR) GUARDIANSHIP 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. IF THE APPLICATION IS FOR A GUARDIANSHIP OF THE ESTATE (R.C. 2111.03): a. The whole estate of the prospective ward is: Personal Property ................................................................ Real Property ..................................................................... Annual Rents ..................................................................... Other Annual Income ........................................................... TOTAL.............. $_______________________ $_______________________ $_______________________ $_______________________ 0.00 $_______________________ b. A bond in the amount of $_____________________________is attached as Exhibit A (R.C. 2109.04(A)(1)). 5. LIST THE NEXT-OF-KIN OF THE MINOR(S), WHO RESIDE IN THE STATE, FOR SERVICE OF NOTICE, AND WAIVER(S), IF ANY, ARE ATTACHED AS EXHIBIT B (R.C. 2111.03). 6. INFORMATION CONCERNING THE PROSPECTIVE GUARDIAN/APPLICANT (R.C. 2111.03): a. Name and AKA _____________________________________________________________________ Home Address ______________________________________________________________________ ___________________________________________________________________ ZIP ____________ Relationship to Minor (s) _____________________________________________________ Occupation __________________________________________________________________________ Work Address _______________________________________________________________________ ___________________________________________________________________ ZIP ____________ Telephone: Home _________________________ Work ____________________________ b. FIDUCIARY'S ACCEPTANCE IS ATTACHED AS EXHIBIT C. c. IF THE APPLICATION IS FOR PERSON ONLY. AN AFFIDAVIT OF CUSTODY IS ATTACHED AS EXHIBIT D. d. Applicant (is/is not) an administrator, executor, or other fiduciary of the estate wherein the alleged incompetent is interested. (R.C. 2111.09) e. Applicant (has/has not) been charged with, or convicted of, a crime involving theft; physical violence; or sexual, alcohol, or substance abuse. If the Applicant has been so charged or convicted, list the dates and places of the charge (s) or conviction (s) (R.C. 2111.03(A)): Charge/Conviction ________________________________ Date _________________ Place _____________________ American LegalNet, Inc. www.FormsWorkFlow.com ________________________________ ________________________________ ________________________________ ________________________________ f. Attorney representing the Applicant is: _________________ _________________ _________________ _________________ _____________________ _____________________ _____________________ _____________________ Name _____________________________________________________________________________ Address ___________________________________________________________________________ _______________________________________________________________ ZIP _______________ Telephone _______________________________________ ID Number _______________________ 7. The person who has custody is ____________________________________________________________ and the address is _______________________________________________________________________ _____________________________________________________________________(R.C. 2111.03(A)(4)). does does not consent to the selection of the applicant 8. If the minor's age is over 14 years, he/she as guardian. Consent is attached as part of Exhibit B (R.C. 2111.12). I hereby petition the Court to be appointed Guardian of the foregoing-described minor(s), and certify that all the information and statements contained in this application and attached exhibits are correct to the best of my knowledge and belief. _______________________________________ Attorney for Applicant _________________________________________ Applicant Sworn to before me, and signed in my presence, this ____________ day ____________________, 20 _______. _________________________________________ Notary Public/Deputy Clerk KNOWINGLY GIVING FALSE INFORMATION ON A PROBATE DOCUMENT IS A CRIMINAL OFFENSE. (R.C. 2921.13(A)(11)) Print Reset American LegalNet, Inc. www.FormsWorkFlow.com