Waiver {5F}

PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE NAME CHANGE OF: GUARDIANSHIP OF: CASE NO.: WAIVER INSTRUCTIONS: Read the below waiver. If you agree, sign on the Applicant's Signature blank. I acknowledge that I have completed and submitted an Applicant Information form (M.C. Form 5F.1) in the above-captioned case. I grant Montgomery County Probate Court permission to use the information contained in the Applicant Information form to request all criminal history information pertaining to me in the files of the Ohio Courts Network. I release the Ohio Courts Network and any and all individuals involved in responding to such request from any and all liability in connection with the dissemination of such information. I understand that although the Applicant Information form will not become public record, information received from the Ohio Courts Network may become a part of the Court's case file, and therefore, may become public record. Date Applicant's Signature Applicant's Printed Name American LegalNet, Inc. www.FormsWorkFlow.com M.C. FORM 5F ­ WAIVER 6/1/16