PROBATE COURT OF LUCAS COUNTY, OHIO JUDGE JACK R. PUFFENBERGER IN THE MATTER OF THE ADOPTION OF _______________________________________ CASE NO. APPLICATION FOR PLACEMENT BY BIRTH PARENT(S) Now comes __________________________________, and represents that she/he is the mother/father of ___________________________________, born on the ___ day of ___________________, 20 ___ at __________________________. Said applicant further represents that she/he is ____ years of age; her/his current address is _____________________________________________and that _______________________________ is also a biological parent of said child. It is proposed by said applicant to place ___________________________ in the home of _______________________ and ________________________, who are husband and wife; related to me as _________________________; their address is _________________________________________________ for the purpose of having them adopt said child. Said applicant further represents that said placement would be in the best interests of said child. Wherefore, your applicant prays the Court to approve said proposed placement. The above named __________________________________ being duly sworn, says that the facts stated and allegations in the foregoing application contained are true as she/he verily believes. Birth Father Phone Number (include area code) _________________________ Attorney (Signature) Birth Mother Phone Number (include area code) Date _________________________ Attorney (Print Full Name) _________________________ Address _________________________ _________________________ Phone Number LCPC FORM 20.3-A American LegalNet, Inc. www.FormsWorkFlow.com