PROBATE COURT OF STARK COUNTY, OHIO ADOPTION OF CASE NO. DIXIE PARK, JUDGE (Name after adoption) PETITIONER'S ACCOUNT (R.C. 3107.055) 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 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 O.R.C. 3107.055(C)(9) FOSTER CARE GUARDIAN AD LITEM COURT COSTS ALL OTHER DISBURSEMENTS TOTAL FORM 18.9 - PETITIONER'S ACCOUNT 09/1/2011 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 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 , 20 _____. day of Petitioner Petitioner American LegalNet, Inc. www.FormsWorkFlow.com