PROBATE COURT OF SHELBY COUNTY, OHIO IN THE MATTER OF THE PLACEMENT OF _________________________________ (Current Name of Child) CASE NO. ___________________________ APPLICATION BY RELATIVE FOR APPROVAL OF PLACEMENT [R.C. 5103.16(D)] Applicant, ________________________________________________________________________, who resides at (Name of relative) ___________________________________________________________________________ represents that applicant is the (Address of relative) ____________________________________ of a child whose date of birth is ___________________________ and (Relationship to child) (Birthdate of child) who resides at ________________________________________________________________________________. (Address of child) Applicant states that: (Check whichever applicable) the mother of the child is deceased. the father of the child is deceased. the mother as established pursuant to R.C. 3111.02(A) has abandoned the child as determined under R.C. 3107.07(A). the father as established pursuant to R.C. 3111.02(A) has abandoned the child as determined under R.C. 3107.07(A). Applicant proposes that said child be placed for adoption and states that such proposed placement would be in the best interest of the child. Applicant requests that the Court order an independent home study of the proposed placement to be conducted as provided in section 3107.031 of the Revised Code. Applicant consents to the proposed placement. Applicant requests that a hearing be set to allow the Applicant to appear before the Court concerning the proposed placement. WHEREFORE, Applicant prays that such proposed placement be approved. ___________________________________________ Signature of Relative SCPC FORM 316 ­ APPLICATION BY RELATIVE FOR APPROVAL OF PLACEMENT American LegalNet, Inc. www.FormsWorkFlow.com