PROBATE COURT OF LUCAS COUNTY, OHIO JUDGE JACK R. PUFFENBERGER IN RE: INFANT CASE NO. APPLICATION TO PLACE UNBORN CHILD FOR ADOPTION Now comes ________________________________, the birth parent of a presently unborn child and states that she/he is _____ years old. Birth mother also believes ______________________________________ to be the birth father. Child is due to be born about ______________________ at _______________________Hospital. Birth parent is aware that Court requires a Mandatory Assessment to be completed by a Court-Appointed Assessor and agrees to said requirement. Birth parent further states that she/he is aware that prior to the Placement Hearing, all medical records regarding the infant and the birth parent(s) shall be provided to the attorney representing the prospective adoptive applicant(s). Birth parent is also aware that this Placement Hearing must be held anytime after 72 hours from the time of the infant's birth. She/he further states that she/he is aware of his/her right to contest the decree of adoption subject to the limitations of Section 3107.16 of the Ohio Revised Code. Birth parent further authorizes the Court to order the hospital to release said child to foster care prior to the Court's Placement hearing. ______________________________ Birth Mother ______________________________ Birth Mother (Please Print Name) ______________________________ Address ______________________________ ______________________________ Phone No. ______________________________ Attorney ______________________________ Attorney Name (Please Print Name) ______________________________ Address ______________________________ ______________________________ Phone Number LCPC Form 20.3 American LegalNet, Inc. www.FormsWorkFlow.com ______________________________ Birth Father ______________________________ Birth Father (Please Print Name) ______________________________ Address ______________________________ ______________________________ Phone No. Date