Statement Of Additional Information {17.0F}

PC-G-17.0F (Rev. 2-2016) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. STATEMENT OF ADDITIONAL INFORMATION Now comes the applicant for the appointment of guardian of the person and/or estate of the above captioned person, and answers the following questions with respect to the prospective ward. 1. Is the ward eligible for or receiving any of the following benefits, and if so, where are they or their source located? TYPE NAME AMOUNT PER MONTH Social Security ....................................................................................................... P.E.R.S. ................................................................................................................. Veterans Administration .......................................................................................... R.R. Retirement ..................................................................................................... Employee's Pension Insurance Benefits ....................... ....................... $ A.D.C. .................................................................................................................... Other ....................... 2. Does the prospective ward have an interest in an estate or trust? If so, give the decedent's name, Court case number, name and location of Court, or trustee, etc. 3. Is the alleged incompetent the beneficiary of a special needs trust? Yes No 4. Does the prospective ward have an expectancy from any minor's settlement? If so, give the defendant's name or his insurer's name, and the amount expected. 4. Cash? Yes No Amount: 5. Bank, Savings and Loan, Brokerage and other financial accounts describe below: 15.3 FRANKLIN COUNTY FORM 17.0F - STATEMENT OF ADDITIONAL INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. INSTITUTION ADDRESS ACCOUNT CURRENT BALANCE $ 6. Securities? ISSUER: Yes No [if yes, describe below.] ................................ ................................ ................................ $ CURRENT VALUE 7. Land installment contracts? VENDEE & ADDRESS Yes No [if yes, describe below.] PROPERTY LOCATION AMT. PER MO. & BALANCE / / 8. Rental from real estate? Yes ADDRESS OF REAL ESTATE No [if yes, describe below.] AMT. PER MO. 9. Interest in real estate? Yes ADDRESS OF REAL ESTATE No [if yes, describe below.] 10. Income from any other source? Yes No [if yes, describe below.] 11. Other assets? Yes No [if yes, describe below.] 15.3 Applicant FRANKLIN COUNTY FORM 17.0F - STATEMENT OF ADDITIONAL INFORMATION (PAGE 2) American LegalNet, Inc. www.FormsWorkFlow.com