Affidavit Of Intellectual Disability {50.6B}

PC-DD-50.6B (Rev.12-2016) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF CASE NO. AFFIDAVIT OF INTELLECTUAL DISABILITY [R.C.5123.71] The State of Ohio, Franklin County, s.s. the undersigned, residing at says that they have information or actual knowledge to believe that the respondent is a person with an intellectual disability who resides or is institutionalized at , Franklin County, Ohio, and that the person is subject to involuntary institutionalization by court order, pursuant to R.C. 5123.71 as defined by R.C. 5123.01(N)(O). This allegation is that the above respondent is a: "Person with an intellectual disability subject to institutionalization by court order" who is a person age eighteen or older, is at a moderate level of intellectual disability and, because of their disability, the following condition(s) exist: (1) The person represents a very substantial of physical impairment or injury to himself as manifested by evidence that he is unable to provide for and is not providing for his most basic physical needs and that provision for such needs is not available in the community; (2) The person needs and is susceptible to significant habilitation in an institution. In addition, affiant provides the following factual grounds for the belief that the respondent is subject to institutionalization by court order Attached hereto is either a comprehensive evaluation report including a statement by the evaluation team that they have performed a comprehensive examination of the person and that they are of the opinion that the person has an intellectual disability and is subject to institutionalization by court order, or a written and sworn statement that the person or that the guardian of a minor or adjudicated incompetent person has refused to allow a comprehensive evaluation. FRANKLIN COUNTY FORM DD-50.6B - AFFIDAVIT OF INTELLECTUAL DISABILITY (PAGE 1) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. The name and address of respondent's legal guardian, if any, is: The identification of the adult next of kin of the respondent follows: NAME ADDRESS KINSHIP AGE That the following constitutes additional information that may be necessary for the purpose of determining residence: Dated this day of , 20 . Affiant Sworn to before me and signed in my presence on the day and year above dated. Notary Public/Deputy Clerk WAIVER I, the undersigned affiant, hereby waive the issuing and service of Notice of the Hearing on this Affidavit, and voluntarily enter my appearance herein. Date Affiant FRANKLIN COUNTY FORM DD-50.6B - AFFIDAVIT OF INTELLECTUAL DISABILITY (PAGE 2) American LegalNet, Inc. www.FormsWorkFlow.com