PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE GUARDIANSHIP OF CASE NO. APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT [R.C.2111.03] Applicant represents to the Court that resides or has a legal settlement at in County, Ohio and that the prospective ward is incompetent by reason of (R.C. 2111.01(D)) . The proposed ward's date of birth is A Statement of Expert Evaluation is Attached. (Form 17.1) A list of Next of Kin of Proposed Ward is also attached. (Form 15.0) The whole estate of the prospective ward is estimated as follows: Personal Property..................... $ Real Estate ............................... $ Annual Rents ........................... $ Other annual income................ $ Applicant represents that the applicant is not an administrator, executor or other fiduciary of the estate wherein the alleged incompetent is interested. Applicant offers the attached bond in the amount of $ . . Applicant further represents that a guardian of the alleged incompetent is necessary in order that the ward ward's property may be taken proper care of and asks that a guardian be appointed. TYPE OF GUARDIANSHIP APPLIED FOR IS non-limited limited [check the applicable boxes] person and estate estate only person only If limited guardianship is applied for, the limited powers requested are . FORM 17.0 APPLICATION FOR APPOINTMENT OF GUARDIAN (AN ALLEGED INCOMPETENT) 1/1/13 American LegalNet, Inc. www.FormsWorkFlow.com [REVERSE OF FORM 17.0] CASE NO. The time period requested is indefinite definite to . Applicant's relationship to alleged incompetent is . The Applicant has (not) been charged with or convicted of a crime involving theft, physical violence, or sexual, alcohol or substance abuse except as follows (if applicable, state date and place of each charge or each conviction.) . The Applicant represents that a guardian has been nominated in a writing pursuant to R.C. 1337.09(D) or R.C. 2111.121 . The nominated person is The nominated person's contact information is listed on Form 15.0 (Next of Kin). A copy of the document which nominates the guardian is attached. The Applicant represents that the proposed ward had military service . Military I.D.:__________________________________ Branch of Service: ____________________________ Dates of Service: __________________________________ Applicant represents that the address provided is the applicant's permanent address and acknowledges the requirement that the court be notified of any change of address. Removal may result from a failure to comply with this requirement. Attorney for Applicant Applicant Typed or Printed Name Typed or Printed Name Address Age City State Zip Address Phone number (include area code) City State Zip Attorney Registration Number Phone number (include area code) 1/1/13 FORM 17.0 - APPLICATION FOR APPOINTMENT OF GUARDIAN (AN ALLEGED INCOMPETENT) PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com