PROBATE COURT OF SHELBY COUNTY, OHIO PLACEMENT OF CASE NO. (Name before placement) PRE - PLACEMENT APPLICATION The undersigned, being husband and wife, hereby make application to be approved for placement of a child for purposes of adoption pursuant to Section 5103.16(D) of the Ohio Revised Code, and state the following facts. 1. Husband's name: Last First Middle 2. Wife's name: Last First Middle 3. Residence address: Street City County State 4. Expected birth date of infant: Wherefore, your applicant(s) pray that the Court make an investigation concerning themselves and the information contained in this Application, for which authority is hereby given, and to approve them as proposed adopting parents for placement of a child by virtue of Ohio Revised Code Section 5103.16(D) Attorney for Prospective Adoptive Parents Husband Typed or Printed Name Typed or Printed Name Add ress Wife Typed or Printed Name Phone Number (include area code) Phone Number (include area code) American LegalNet, Inc. www.FormsWorkFlow.com Attorney Registration Number H.C. FORM 118.20 - PRE - PLACEMENT APPLICATION 02/10/03