PROBATE COURT OF CUYAHOGA COUNTY, OHIO

1 PROBATE COURT OF CUYAHOGA COUNTY, ohio ANTHONY J. RUSSO, PRESIDING J UDGE LAURA J. GALLAGHER, JUDGE GUARDIANSHIP OF CASE NO. APPLICATION FOR APPOINTMENT OF GUARDIAN OF ALLEGED INCOMPETENT [ ] Applica nt represents to the COURT that resides or has a l egal settlement at in C ounty, ohio and that the prospective ward is incompetent by reason of ( (d)) _____ . The proposed ward s date of birth is . A Statement of Expert Evaluation is attached. (Form ) A list of Next of Kin of Proposed W ard is also attached. (Form ) The whole estate of the prospective ward is estimated as follows: Personal Pr $ Real $ Annual $ Other annual $ Applica nt represents th at the applicant is not an administrator, executor or other fi duciary of the estate wherein the alleged incompetent i s interested. Applica nt o ff ers the attached bond in the amount of $.

2 Applica nt further represents that a guardian of the alleged incompetent i s necessary in order th at the ward ward's property may be taken proper care of and asks that a guardian be appointed. TYPE OF GUARDIANSHIP APPLIED FOR IS [check the applicable boxes] non-limited limited person and estate estate only person only If limited guardianship is applied for, the limited powers requested are . FORM APPLICATION FOR A PPOINTMENT OF GUARDIAN (AN ALLEGED INCOMPETENT) Amended: January 1, 2013 Di scard all previous versions of this fo rm [Reverse of Form ] CASE NO. The time period requested is indefinite definite 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.)

3 The Applicant represents that a guardian has been nominated in a writing pursuant to (D) or The nominated person is . The nominated person s contact information is listed on Form (Next of Kin). A copy of the document which nominates the guardian is attached. The Applicant represents that the proposed ward had military service. Military : Branch of service: Dates of service: Applicant represents that the address provided is the applicant's permanent address and acknowledges the requirement that the COURT be notified of any change of address. Removal may result from a failure to comply with this requirement. attorney for Applicant Applicant Typed or Printed Name Typed or Printed Name Address Age City State Zip Permanent Address Telephone Number (include area code) City State Zip attorney Registration No.

4 Telephone Number (include area code) FORM APPLICATION FOR APPOINTMENT OF GUARDIAN (AN ALLEGED INCOMPETENT) Page 2 Amended: January 1, 2013 Discard all previous versions of this form PROBATE COURT OF CUYAHOGA COUNTY, OHIOANTHONY J. RUSSO Presiding JudgeLAURA J. GALLAGHER, JudgeIN THE MATTER OF THE GUARDIANSHIP OF _____CASE NUMBER_____NEXT OF KIN OF PROPOSED WARD( )(NOTE:Specify age and birthdate of each minor under 16 on the line containing the minor s name. List the name andaddress of the minor s parent, guardian, or custodian on the name and address line following the minor s address.)ServiceBirthdateWaivedRelations hipof Minor1. GName _____ _____ _____Address _____ Zip _____2. GName _____ _____ _____Address _____ Zip _____3. GName _____ _____ _____Address _____ Zip _____4. GName _____ _____ _____Address _____ Zip _____5. GName _____ _____ _____Address _____ Zip _____6.

5 GName _____ _____ _____Address _____ Zip _____7. GName _____ _____ _____Address _____ Zip _____8. GName _____ _____ _____Address _____ Zip _____9. GName _____ _____ _____Address _____ Zip _____10. GName _____ _____ _____Address _____ Zip - Next of Kin of Proposed WardWAIVER OF NOTICE AND CONSENTWe, the undersigned, do each of us hereby waive the issuing and service of notice, andvoluntarily enter our appearance do hereby consent to the appointment of _____or some suitable person as guardian of _____ _____ _____ _____ _____ _____ _____ PROBATE COURT OF CUYAHOGA COUNTY, OHIOANTHONY J. RUSSO Presiding JudgeLAURA J. GALLAGHER, JudgeIN THE MATTER OF _____CASE NUMBER _____FIDUCIARY'S ACCEPTANCE GUARDIAN[ ]I, the undersigned, hereby accept the duties which are required of me by law, and such additional duties asare ordered by the COURT having GUARDIAN OF THE ESTATE, I WILL: and file an inventory of the real and personal estate of the ward within 3 months after myappointment.

6 Funds which come into my hands in a lawful depository located within this state. surplus funds in a lawful manner. and file an account biennially, or as directed by the COURT . a final account within 30 days after the guardianship is terminated. any safe deposit box of the ward. any and all Wills of the Ward as directed by the COURT funds only upon written approval of the COURT . and file a guardian s report biennially, or as directed by the GUARDIAN OF THE PERSON, I WILL: and control the person of my ward when necessary and make all decisions for the ward basedupon the best interest of the ward. suitable maintenance for my ward when necessary. such maintenance and education for my ward as the amount of his estate justifies if the wardis a minor and has no father or mother, or has a father or mother who fails to maintain or educatehim/her. and file a guardian s report biennially, or as directed by the COURT .

7 All orders and judgments of the COURT pertaining to the guardianshipIf I change my address or the ward s address, I shall immediately notify PROBATE COURT inwriting. I acknowledge that I am subject to removal as such fiduciary if I fail to perform such duties. I alsoacknowledge that I am subject to possible penalties for improper conversion of the property which I hold Fiduciary's Acceptance - Guardian01/09 PROBATE COURT OF CUYAHOGA COUNTY, OHIOANTHONY J. RUSSO Presiding JudgeLAURA J. GALLAGHER, JudgeIN THE MATTER OF THE GUARDIANSHIP OF _____CASE NUMBER_____STATEMENT OF EXPERT EVALUATION[Sup. R. 66 & ]Definition of Incompetent ( (D)): Incompetent means any person who is somentally impaired as a result of a physical or mental illness or disability, or mental retardation, or as aresult of chronic substance abuse, that the person is incapable of taking proper care of the person sself or property or fails to provide for the person s family or other persons for whom the person ischarged by law to provide, or any person confined to a correctional institution within this State.

8 The Statement of Evaluation does not declare the individual competent or incompetent, but isevidence to be considered by the COURT . The fee for completing the evaluation WILL NOT be paid bythe PROBATE COURT . Each evaluator should secure payment from the Statement of Expert Evaluation is to be filed with or attached Application. Completed by 9 Licensed Physician or 9 Licensed Clinical Psychologist prior to the filing and attached to s Report: Completed by 9 Licensed Physician 9 LicensedClinical Psychologist 9 Licensed Independent Social Worker 9 LicensedProfessional Clinical Counselor or 9 Mental Retardation Team The evaluation or examination shall be completed within three months prior tothe date of the Report. for Emergency Guardian: 9 of the person: a Licensed Physicianshall complete the Supplement for Emergency Guardian, Form A withspecificity indicating the emergency, and why immediate action is required toprevent significant injury to the person.

9 The Supplement shall be signed, dated,and attached as part of this completed completed by:Name & Title/Profession: _____Business Address: _____ Business Telephone Number: (s) of evaluation: _____Place(s) of evaluation: _____Amount of time spent of evaluation: _____ Length of time the individual has been your patient: Statement of Expert Evaluation CASE the individual presently under medication? 9 Yes 9 No If yes, what is themedication, dosage, and purpose? _____Are there any signs of physical and/or mental impairments caused by the medications themselves? the individual mentally impaired? 9 Yes 9 No If yes, indicate the diagnosis below:9 Mental Retardation/Developmental Disabilities:9 Profound9 Severe 9 Moderate 9 Mild9 Mental Illness: Type and Severity _____ _____9 Substance Abuse: Description _____9 Dementia: Description _____9 Other: Description _____Please provide additional comments and test scores if available.

10 (Continue comments on page 4): the examination did you notice an impairment of the individual s:a) Orientation9 Yes9 No9 Unknownb) Speech9 Yes9 No9 Unknownc) Motor Behavior9 Yes9 No9 Unknownd) Thought Process9 Yes9 No9 Unknowne) Affect9 Yes9 No9 Unknownf) Memory9 Yes9 No9 Unknowng) Concentration and Comprehension9 Yes9 No9 Unknownh) Judgment 9 Yes9 No9 describe any impairments identified in question six. (Continue comments on page 4)_____Page 2 CASE the individual physically impaired? 9 Yes 9 No If yes: Description there any special characteristics of the individual which should be considered in evaluatingthe individual for guardianship?: 9 Yes 9 No If yes: Explain there any indications of abuse, neglect or exploitation of the individual? 9 Yes 9 No If yes: Explain you believe the individual is capable of caring for the individual s activities of daily living ormaking decisions concerning medical treatments, living arrangements and diet?