PROBATE COURT OF ___________________________COUNTY, OHIO _______________________________, JUDGE IN THE MATTER OF __________________________________________, AN ADULT CASE NO. _________________ NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES [R.C. 5101.66] TO: __________________________________________________________________________ Name and Address of Adult Incapacitated Person Name Address Relationship of Adult __________________________________________________________________________ Adult, Guardian, Legal Counsel, Caretaker, Spouse, if any, and if none of these to the Adult’s Children or Next of Kin You are hereby notified that on the _______ day of __________, 20 _____, the ________County Department of Job and Family Services filed in this Court a Petition for Court Ordered Protective Services for the above named Adult for the following reason(s): _________________ _____________________________________________________________________________. This Petition for Court Ordered Protective Services shall be heard in the _____________County Probate Court, ________________, Ohio located at ___________________________________ on the ______ day of __________, 20 ____, at ___________o’clock ______.M. The Adult has the right to legal counsel and if indigent, legal counsel will be appointed if requested. Witness my signature and the seal of the Court this _____ day of ____________, 20 _______. ______________________________________ Probate Judge By: ______________________________________ Deputy Clerk WAIVER OF NOTICE We, the undersigned, whose relationship to the Adult is indicated, enter our appearance and waive notice and consent to the hearing. Name Relationship to the Adult ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ FORM 23.1 – NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.__________________________ 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 _____________, 20_______, 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 23.1 – NOTICE OF PETITION FOR COURT ORDERED PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com