PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE ADOPTION OF (Name after adoption) CASE NO. PETITIONER'S ACCOUNT (R.C. 3107.10) 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 have 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 NAME AND ADDRESS DISBURSEMENTS MADE OR AGREED TO BE MADE COSTS PHYSICIAN 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 FOSTER CARE GUARDIAN AD LITEM COURT COSTS ALL OTHER DISBURSEMENTS TOTAL Page 1 of 2 FORM 18.9 - PETITIONER'S ACCOUNT 10/01/97 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. [Reverse of Form 18.9] CERTIFICATION OF PETITIONER'S ACCOUNT The undersigned certifies this and accurate. day of , , that this accounting is true Attorney or Agency Typed or Printed Name Address City State Telephone Number (include area code) day of The petitioner has reviewed this accounting and attests to its accuracy this , . Petitioner Petitioner ORDER APPROVING PETITIONER'S ACCOUNT The Petitioner's Account filed in accordance with R.C. 3107.10 is hereby approved. William R. Zimmerman, Probate Judge Page 1 of 2 FORM 18.9 - PETITIONER'S ACCOUNT American LegalNet, Inc. www.FormsWorkflow.com