PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE CONSERVATORSHIP OF: CASE NO.: APPLICATION FOR APPOINTMENT OF CONSERVATOR [R.C. 2111.021] I, am physically infirm. I request that: 1. Name of Proposed Conservator Street City 2. 3. Person and Estate Indefinite Ohio (Zip) Person Only Telephone Estate Only be appointed conservator of my: The length (time period) of the conservatorship is: Definite ­ to (If "Person Only" or "Person and Estate" is checked), I give the following power over my PERSON to the: a. Conservator: (1) (2) All powers that a guardian would have under the guardianship laws of Ohio. Limited to the power to: , Petitioner, hereby state that I am a competent adult but b. Court: (1) (2) All powers that a Court would have under the guardianship laws of Ohio. Limited to the power to: 4. (If "Estate Only" or "Person and Estate" is checked), I give the following power over my ESTATE to the: a. Conservator: (1) (2) All powers that a guardian would have under the guardianship laws of Ohio. Limited to the power to: FORM 20.0 ­ APPLICATION FOR APPOINTMENT OF CONSERVATOR 6/1/16 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ____________________ b. Court: (1) (2) All powers that a Court would have under the guardianship laws of Ohio. Limited to the power to: c. The following of my property is subject to the foregoing powers: (1) (2) All property (attach description of property) Only the property listed as follows: 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 TOTAL b. A bond in the amount of $ (R.C. 2109.04(A)(1))(Form 15.3) is attached. $ $ $ $ $ 6. Service of notice of the conservatorship is to be given to: None Same as Guardianship 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 __________________________________________ Attorney's Signature __________________________________________ Attorney's Printed Name __________________________________________ Address __________________________________________ City State Zip Code __________________________________________ Telephone Number __________________________________________ Attorney Registration Number __________________________________________ Applicant's Signature __________________________________________ Applicant's Printed Name __________________________________________ Address __________________________________________ City State Zip Code __________________________________________ Telephone Number __________________________________________ Applicant's Email Address 6/1/16 American LegalNet, Inc. www.FormsWorkFlow.com FORM 20.0 ­ APPLICATION FOR APPOINTMENT OF CONSERVATOR