PROBATE COURT OF WARREN COUNTY, OHIO IN THE MATTER OF GUARDIANSHIP OF ___________________________________ Case No. ______________________ APPLICATION FOR APPOINTMENT OF EMERGENCY GUARDIAN OF ALLEGED INCOMPETENT Application represents to the Court that _________________________________________________ aged _________________ years, 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)) __________________________________________________. Applicant further represents that an emergency exists and that is it reasonably certain that immediate action is required to prevent significant injury to the person or estate of the proposed ward. A Statement of Expert Evaluation is attached. (Form 17.1) A List of Next of Kin of the Proposed Ward is also Attached (Form 15.0), however, applicant requests that the Court act ex parte, without notice because of the emergency existing. The whole estate of the prospective ward is estimated as follows: Personal property................................................ $ ____________________ Real estate........................................................ $ ____________________ Applicant represents that _____ is not an administrator, executor or other fiduciary of the estate wherein the alleged incompetent is interested. Application 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. PRESENT LOCATION OF WARD: ____________________________________________________________ Street ________________________________________________________________________________________ City State Zip Code TYPE OF GUARDIANSHIP APPLIED FOR IS EMERGENCY ____ limited ____ person and estate ____ estate only ____ person only The limited powers requested are: consenting or withholding consent for medical treatment and personal care; authorizing hospitalization American LegalNet, Inc. www.USCourtForms.com or other residential institutionalization. _________________________________________________________________________________. The time period requested is from ___________________________ 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): ________________________________________________________________________________________ _______________________________________________________________________________________. _________________________________________ Attorney for Applicant _________________________________________ Applicant _________________________________________ Type or Print name _________________________________________ Type or Print name _________________________________________ Address _________________________________________ Age Social Security Number _________________________________________ City, State, Zip Code _________________________________________ Address _________________________________________ Phone number (include area code) _________________________________________ City, State, Zip Code _________________________________________ Supreme Court Registration Number _________________________________________ Phone number (include area code) KNOWINGLY GIVING FALSE INFORMATION ON A PROBATE DOCUMENT IS A CRIMINAL OFFENSE. [R.C. 2921.13 (A)(11)] American LegalNet, Inc. www.USCourtForms.com