Affidavit Of Supervision Administrator {516}

<document>PROBATE COURT OF BUTLER COUNTY, OHIOIN THE MATTER OFCase No.AFFIDAVIT OF SUPERVISOR/ADMINISTRATORAffiant being first duly sworn, deposes and says: In accordance with the order of this Court dated,the above named ward was(Action Taken Regards the Ward)Sworn to before me and subscribed in my presence thisday of.,Notary Public1.The affidavit must be signed by a supervisor/administrator of a rest home or facility (if ward was admitted to same), doctor or medical provider (if ward was hospitalized, medicated or surgical procedures performed), etc. 2.This form must be RETURNED to the Butler County Probate Court NO LATER THAN FIVE (5) DAYS after the expiration of the 72 hour order.12/97BCPC FORM 516 -AFFIDAVIT OF SUPERVISOR/ADMINISTRATOR2001 © American LegalNet, Inc.</document>