PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of:___________________________________________________________________________ Respondent Alleged to be Mentally Ill Case No. ___________________________ APPLICATION FOR RELEASE OF INFORMATION FROM CIVIL COMMITMENT FILE [R.C. 5122.31] Now comes ___________________________________________and requests the Court to release to him/her the information in the Court's file in the above-captioned matter. In making such Application, applicant affirms the following: ¨ I am the respondent in this case. ¨ I am the guardian of the respondent in this case. Filed with this Application is a certified copy of my Letters of Guardianship. ¨ The respondent has agreed to the release of information to me. Filed with this Application is his/her waiver of hearing and consent. ¨ The guardian of the respondent has agreed to the release of information to me. Filed with this Application are the guardian's waiver of notice of hearing and consent and a certified copy of the Letters Guardianship. ¨ The requested release of information is in the best interest of the respondent for the following reasons: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ [If the respondent is deceased, check the appropriate boxes for the following statements. If respondent is deceased, a certified death certificate must be filed with this application.] ¨ I am the executor or administrator of the estate of the respondent. Filed with this Application is a certified copy of my Letters of Authority. The information contained in respondent's civil commitment file is necessary to administer his/her estate. ¨ I was related to the respondent in the following manner: _________________________________________________________________________ ¨ There are others, now living, who were as closely, or more closely related to the respondent. The names, addresses, and relationships of these persons are listed on Form 1.0, which is filed with this Application. ¨ I have obtained consents for release of information from ___ none; ___ some; ___ all of those listed on Form 1.0. These consents are filed with this application. FORM 600.17 - APPLICATION FOR RELEASE OF INFORMATION FROM CIVIL COMMITMENT FILE Crensch$\forms\600.17.d0c 11/30/01 American LegalNet, Inc. www.USCourtForms.com The reasons for my desiring the release of this confidential information are as follows: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Attorney Signature Applicant's Signature Typed or Printed Name Typed or Printed Name Street Address Street Address City, State, Zip City, State, Zip Telephone No. Telephone No. Attorney Registration No. American LegalNet, Inc. www.USCourtForms.com