PROBATE COURT OF MONTGOMERY COUNTY, OHIO ADOPTION OF _____________________________________________________ (Name after adoption) CASE NO. ________________________ PETITIONER'S ACCOUNT [R.C. 3107.55] PRELIMINARY ESTIMATE ACCOUNTING (To be filed not later than date petition filed) FINAL ACCOUNTING (To be filed not later than 10 days prior to date of final hearing) This accounting specifies all disbursements of anything of value the petitioner, a person on the petitioner's behalf, and the agency or attorney made and has agreed to make in connection with the minor's permanent surrender under division (B) of Section 5103.15 of the Revised Code, placement under Section 5103.16 of the Revised Code, and adoption under Chapter 3107. (Attach extra sheets if necessary) DATE PHYSICIAN NAME AND ADDRESS DISBURSEMENTS MADE OR AGREED TO BE MADE ACTUAL COSTS HOSPITAL/MEDICAL FACILITY ATTORNEY ACTUAL COST TO THE ATTORNEY AGENCY ACTUAL COST TO THE AGENCY MAINTENANCE AND MEDICAL CARE REQUIRED UNDER R.C. 5103.15 EXPENSES PURSUANT TO R.C. 3107.55(C)(9) FOSTER CARE GUARDIAN AD LITEM COURT COSTS ALL OTHER DISBURSEMENTS TOTAL 18.9 - PETITIONER'S ACCOUNT Amended: September 1, 2011 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ___________________ [Reverse of Form 18.9] CERTIFICATION OF PETITIONER'S ACCOUNT The undersigned certifies this _______ day of ___________________________, 20____, that this accounting is true and accurate. _____________________________________ Attorney or Agency _____________________________________ Typed or Printed Name _____________________________________ Address _____________________________________ City State _____________________________________ Telephone Number (include area code) The petitioner has reviewed this accounting and attests to its accuracy this _______ day of _________________________, 20____. _______________________________________________ Petitioner _______________________________________________ Petitioner 18.9 - PETITIONER'S ACCOUNT PAGE 2 Amended: September 1, 2011 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com