PROBATE COURT OF ___________________________COUNTY, OHIO _____________________, JUDGE IN THE MATTER OF __________________________________________, AN ADULT CASE NO. _______________________ NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES ON AN EMERGENCY BASIS [R.C. 5101.69] TO:__________________________________________________________________________ Name of Adult, spouse, if any, if no spouse, adult children or next of kin, and guardian, if any, if their whereabouts are known. _____________________________________________________________________________________________ You are hereby notified that on the _____ day of _________, 20 ____, the ____________County Department of Job and Family Services filed a Petition for Court Ordered Protective Services to be provided for the above named Adult without the Adult’s consent on the grounds that an emergency exists and that the Department has been unable to obtain the consent of the Adult for protective services to be given. A copy of the petition is attached hereto. The Petition has been set for hearing in the ________________________ County Probate Court, ____________, Ohio located at ________________________ on the _____ day of _____________, 20 _______at ______________ o’clock ______.M. The Adult may appear at the hearing, may present, examine, and cross-examine witnesses, and present evidence to contest the petition. The Adult is entitled to be represented by an attorney and, if found to be indigent, the Adult may request an attorney to be appointed without cost. Witness my signature and the seal of the Court this _____ day of _____________, 20 _____. ______________________________________ Probate Judge By:___________________________________ Deputy Clerk FORM 23.3 – NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES ON AN EMERGENCY BASIS Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.__________________________ The State of Ohio, _________________ County Probate Court I hereby certify that I caused a copy of the within notice to be mailed, by certified mail, to the last known address of ______________________________________________________________________________ at____________________________________________________________________________ ______________________________________________________________________________ at____________________________________________________________________________ ____________________, Probate Judge By:______________________________ Deputy Clerk RETURN ________________________County, Ohio ________________________,___________ Received this notice on the _____ day of ______________, 20_______, at ___________ o’clock _____.M., and on the _____ day of _____________, _________, I served the same by delivering a true copy thereof personally to __________________________________________ ______________________________________________________________________________ _______________________________ FEES _______________________________ Service and return, 1st name, $ _____ _____ Additional names, at $ _____ _____Miles traveled, at $ _____ _____________________ ____________________________________ Sheriff ____________________________________ Deputy Sheriff/Process Server ____________________________________ Name $ _____ Total $ _____ _______________________________ ____________________________________ Title FORM 23.3 – NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES ON AN EMERGENCY BASIS Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com