Application For Placement {19.8}

PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE IN THE MATTER OF THE PLACEMENT FOR ADOPTION OF: ____________________________________ (Name before adoption) CASE NO. ____________________ APPLICATION FOR PLACEMENT [R.C. 5103.16) Now comes _______________________________________________________, Applicant(s), and represent that the Applicant(s) is/are the __________________________________of a child whose date of birth is ______________________. and the Applicant(s) propose to place said child with ______________________________________________________, who reside(s) at ___________________________________________________________, for the purpose of adoption. A. CHILD Name: ________________________________________ Birthplace: _____________________________________ Address: ___________________________________ Sex: _______________ Race: _________________ B. MOTHER OF CHILD Name: ________________________________________ Race: _______________ Deceased: Yes No Date of Birth: ___________________________________ Place of Birth: _______________________________ Present Address: ________________________________ Telephone Number ___________________________ Marital Status at Birth of Child: Single Married Divorced Place of Employment: _____________________________________________________________________________ C. FATHER OF CHILD Name: ________________________________________ Race: _______________ Deceased: Yes No Date of Birth: ___________________________________ Place of Birth: _______________________________ Present Address: ________________________________ Telephone Number ___________________________ Marital Status at Birth of Child: Single Married Divorced Place of Employment: _____________________________________________________________________________ D. WILLFUL FAILURE ALLEGMENTS (If Applicable). Applicant states that: Mother Father _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ E. OTHER CHILDREN OF NATURAL PARENT(S) (Name, Date and Place of Birth and Present Whereabouts) (1) _______________________________________ ________________________________________ ________________________________________ (3) _______________________________________ ________________________________________ ________________________________________ F. GRANDPARENTS OF CHILD (Maternal) ____________________________________ ____________________________________ (Paternal) ____________________________________ ____________________________________ Page 1 (2) ________________________________________ ________________________________________ ________________________________________ (4) ________________________________________ ________________________________________ ________________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ American LegalNet, Inc. www.FormsWorkFlow.com M.C. FORM 19.8 - APPLICATION FOR PLACEMENT Eff. Date: February 8, 2011 G. PROSPECTIVE ADOPTIVE FAMILY (Husband) Name: ________________________________________ Race: _______________ Date of Birth: ___________________________________ Place of Birth: _______________________________ Present Address: ________________________________ Religion: ___________________________________ ______________________________________________ Telephone No.:_______________________________ Marital Status at Birth of Child: Single Married Divorced Previous Marriage(s): _____________________________________________________________________________ Previous Divorce(s); Where Obtained; When; Case Number(s): ____________________________________________ _______________________________________________________________________________________________ Place of Employment:____________________________ Length of Employment: ________________________ Income Per Year: _______________________________ Life Insurance: _______________________________ (Wife) Name: ________________________________________ Race: _______________ Date of Birth: ___________________________________ Place of Birth: _______________________________ Present Address: ________________________________ Religion: ___________________________________ ______________________________________________ Telephone No.:_______________________________ Marital Status at Birth of Child: Single Married Divorced Previous Marriage(s): _____________________________________________________________________________ Previous Divorce(s); Where Obtained; When; Case Number(s): ____________________________________________ _______________________________________________________________________________________________ Place of Employment:____________________________ Length of Employment: ________________________ Income Per Year: _______________________________ Life Insurance: ________________ H. HOUSING Renting Buying I. Amount of Rent: _________________ Amount of Mortgage: ______________ Description of Housing Facilities: ________________ Description of Housing Facilities: ________________ OTHER CHILDREN OF PROSPECTIVE ADOPTIVE FAMILY (Name/Birth Date) Husband ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ Wife ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ J. I/WE STATE THAT: I/We have known the prospective adoptive family for ________ years/months. Said child (is) (is not) related to the prospective adoptive family, being _________________________________. The child was not placed by applicant(s) with the prospective adoptive parents for the purpose of adoption. The child (has) (has not) resided in the home of the prospective adoptive parents. Applicant(s) further represent that it is in the best interest of said child that he/she be placed with and received by ____________________________________