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Pre-Placement Application Form. This is a Ohio form and can be use in Lucas County (Court Of Common Pleas).
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Tags: Pre-Placement Application, 20.01, Ohio County (Court Of Common Pleas), Lucas
PROBATE COURT OF LUCAS COUNTY, OHIO
JUDGE JACK R. PUFFENBERGER
Pre-Placement Application
Case No.: _____________________
Applicant_____________________________
(Last, First, Middle)
_____________________________________
Birthdate
Place of Birth
_____________________________________
Race/Ethnic Background
SS#
_____________________________________
Occupation
_____________________________________
Address
_____________________________________
City
State
Zip
Applicant____________________________
(Last, First, Middle)
____________________________________
Birthdate
Place of Birth
____________________________________
Race/Ethnic Background
SS#
____________________________________
Occupation
____________________________________
Phone #
____________________________________
Country
Directions for reaching the residence: _______________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date of Marriage
Licensed Obtained (City, County, State)
Other Members of Household
___________________________
Name
___________________________
Name
___________________________
Name
___________________________
Name
_______________
Birthdate
_______________
Birthdate
_______________
Birthdate
_______________
Birthdate
Has either applicant been married before?
Yes
_____
Sex
_____
Sex
_____
Sex
_____
Sex
__________________
Relation to Applicant
__________________
Relation to Applicant
__________________
Relation to Applicant
__________________
Relation to Applicant
No
If divorced, when and
where was the divorce obtained and identify which applicant. ____________________________
______________________________________________________________________________
No If yes,
Have you ever applied to or adopted a child from any other source? Yes
what source, when and where? ____________________________________________________
LCPC Form 20.1 (page 1of 3)
American LegalNet, Inc.
www.USCourtForms.com
Has either applicant been convicted of a criminal offense? Yes No If yes, what was the
offense? ______________________________________________________________________
Have you had treatment for a serious or chronic illness? Yes
No Explain: _________
______________________________________________________________________________
Have you ever received, or been advised to seek, mental health services? Yes No
Explain: ______________________________________________________________________
Have you ever received, or been advised to seek, treatment for alcohol/substance abuse?
No
Yes
Explain: _______________________________________________________________
Education
_____________________________________
High School
_____________________________________
Other
_____________________________________
____________________________________
High School
____________________________________
Other
____________________________________
Present Employment
_____________________________________
Employer
Phone #
_____________________________________
Length Employed
Salary
____________________________________
Employer
Phone #
____________________________________
Length Employed
Salary
Insurance
_____________________________________
Total Life
Face Value
_____________________________________
Household
Face Value
_____________________________________
Medical
_____________________________________
Other
_____________________________________
____________________________________
Total Life
Face Value
____________________________________
Household
Face Value
____________________________________
Medical
____________________________________
Other
____________________________________
LCPC Form 20.1 (page 2 of 3)
American LegalNet, Inc.
www.USCourtForms.com
List four references who have known you well (include some who know your home life)
______________________ __________________________
___________ ____________
Name
Address
Telephone # Relationship
______________________ __________________________
___________ ____________
Name
Address
Telephone # Relationship
______________________ __________________________
___________ ____________
Name
Address
Telephone # Relationship
______________________ __________________________
___________ ____________
Name
Address
Telephone # Relationship
How long has the child lived in this home ____________________________________________
Is the father legal or putative ______________________________________________________
FOR RELATIVE ADOPTION ONLY:
Relationship of Applicant(s) to Adoptee(s): __________________________________________
Adoptee(s) name(s) as it now appears on birth certificate ________________________________
______________________________________________________________________________
Adoptee(s) name(s)
will remain the same
will be changed to
_________________
______________________________________________________________________________
Adoptee(s) date(s) of birth: _______________________________________________________
Applicant(s) understand that this document is only an application and that additional
information and documentation will be required. Applicant(s) understand that this Court will
require further investigation for purposes of conducting a Homestudy.
_____________________________________
Applicant
____________________________________
Applicant
_____________________________________
Attorney of Record
_____________________________________
Address
_____________________________________
City
State
Zip
_____________________________________
Phone #
_____________________________________
Ohio Supreme Court Number
LCPC Form 20.1 (page 3 of 3)
American LegalNet, Inc.
www.USCourtForms.com