MIKE POWELL, JUDGE Warren County Common Pleas Court Probate-Juvenile Division 570 Justice Drive Lebanon, Ohio 45036 APPLICATION FOR CONSENT TO MARRY OF JUVENILE COURT Juv. R. 42 (A) and (B). The undersigned applicant does hereby make application to the Warren County Juvenile Court for consent to marry in accordance with Juv. R. 42 (A) and (B) and R.C. section 3101.01. The applicant certifies that the information contained in the within application is true to the best of the applicant’s knowledge, information and belief and further acknowledges that the Warren County Juvenile Court will rely upon the information contained herein in determining whether to consent to the applicant’s marriage. 1. Name: ______________________________________________________ 2. Address: ______________________________________________________ ______________________________________________________ 3. Date of birth and current age: Select Month Day Year ______________________________________________________ ______________________________________________________ 4. Parental consent is not required because: Parent(s) resides in a foreign country. Parent(s) has/have neglected or abandoned the applicant for a period of one year or longer immediately preceding the application for a marriage license. Parent(s) has/have been adjudged incompetent. Parent(s) is/are an inmate(s) of a state mental or correctional institution. Parent(s) has/have been permanently deprived of parental rights and responsibilities for the care of the minor and the right to have the minor live with the parent(s) and to be the legal custodian of the minor by a court exercising juvenile jurisdiction. Parent(s) has/have been deprived of parental rights and responsibilities for the care of the minor and the right to have the minor live with the parent and to be the legal custodian of the minor by the appointment of a guardian of the person of the minor by the probate court or by another court of competent jurisdiction. WCJC Form 16 American LegalNet, Inc. www.FormsWorkFlow.com 5. Name and address of parent(s) alleged to have neglected or abandoned the applicant for a period of one year or longer immediately preceding the application for a marriage license. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _________________________________________________________ Applicant’s Signature _________________________________________________________ Applicant’s Address _________________________________________________________ _________________________________________________________ Applicant’s Telephone Number(s) (Day and Evening) Select Month Day Year ___________________________________________ Date WCJC Form 16 American LegalNet, Inc. www.FormsWorkFlow.com