PROBATE COURT OF SUMMIT COUNTY, OHIO ELINORE MARSH STORMER, JUDGE (Name after adoption) ADOPTION OF CASE NO. 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 has 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 R.C. 3107.055(C)(9) FOSTER CARE GUARDIAN AD LITEM COURT COSTS ALL OTHER DISBURSEMENTS TOTAL Form 18.9 ­ PETITIONER'S ACCOUNT (Page 1 of 2) Rev. 09/01/2011 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 Signature Type or Print Name Address City State Zip Telephone Number (include area code) The petitioner has reviewed this accounting and attests to its accuracy this day , 20 . Petitioner Signature Type or Print Name Petitioner Signature Type or Print Name Form 18.9 ­ PETITIONER'S ACCOUNT (Page 2 of 2) Rev. 09/01/2011 American LegalNet, Inc. www.FormsWorkFlow.com