PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the PLACEMENT of:___________________________________________________ (Child's name prior to adoption) Case No. _____________________________ Date:______________________ APPLICATION BY RELATIVE FOR APPROVAL OF PLACEMENT (R.C. 5103.16(D)) Applicant, __________________________________________, who resides at __________________ (Name of relative) __________________________________________ represents that applicant is the ____________________ (Address of relative) (Relationship to child) of a child whose date of birth is __________________ and resides at ________________________________ (Birthdate of child) (Address of child) ________________________________________ Applicant states that: (Check whichever is applicable.) the mother of the child is deceased. the father of the child is deceased. the mother as established pursuant to R.C. 3111.02(A) has abandoned the child as determined under R.C. 3107.07(A). the father as established pursuant to R.C. 3111.02(A) has abandoned the child as determined under R.C. 3107.07(A). Applicant proposes that said child be placed for adoption and states that such proposed placement would be in the best interest of the child. Applicant request that the Court order an independent home study of the proposed placement to be conducted as provided in Section 3107.031 of the Revised Code. Applicant consents to the proposed placement. Applicant requests that a hearing be set to allow the Applicant to appear before the Court concerning the proposed placement. WHEREFORE, applicant prays that such proposed placement be approved _____________________________________ Signature of Relative KNOWINGLY GIVING FALSE INFORMATION ON A PROBATE DOCUMENT IS A CRIMINAL OFFENSE [R.C. 2921.13(A)] FORM 19.10 - APPLICATION BY RELATIVE FOR APPROVAL OF PLACEMENT Crensch$\forms\19.10.doc 1910 American LegalNet, Inc. www.USCourtForms.com 5/15/01