Supplemental Guardianship Conservatorship Information {15-A}

PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF __________________________________________ CASE NO. ____________________ SUPPLEMENTAL GUARDIANSHIP/CONSERVATOR INFORMATION (Attach to all new and successor guardianship or conservator applications) GENERAL CASE INFORMATION (Check one box on each line for items 1 through 7) 1. 2. 3. 4. 5. 6. This is a This application is a The subject is a The fiduciary powers are The application is for a _______ Yes 7. ( ) guardianship ( ) new case ( ) minor ( ) limited ( ) person ( ) conservatorship ( ) successor ( ) incompetent ( ) unlimited ( ) estate ( ) person and estate ( ) conservator Is this case related to any cause pending in any judicial system? _______ No If Yes, describe in detail __________________________ ______________________________________________________________________________ A court reporter and official record is waived for the appointment hearing _______ waived _______ not waived (This waiver may be retracted in writing by counsel or guardian at or before the appointment hearing. However, if necessary, the Court may continue the hearing to schedule a reporter.) INFORMATION CONCERNING THE PROSPECTIVE GUARDIAN/CONSERVATOR Full name and AKA: __________________________________________________________________ Home Address: _______________________________________________________________________ _______________________________________________________________________ Relationship to Ward/Conservatee: _______________________________________________________ Occupation: _________________________________________________________________________ «HE26.B¥- PAGE 1 OF FORM 15-A ­ SUPPLEMENTAL GUARDIANSHIP/CONSERVATORSHIP INFORMATION REV 5/13/08 American LegalNet, Inc. www.FormsWorkFlow.com Telephone No. (Home): ____________________________ (Work): ____________________________ Applicant (is/is not) an administrator, executor, or fiduciary of the estate wherein the proposed ward/conservatee is interest. INFORMATION CONCERNING THE PROPOSED WARD/CONSERVATEE: Full Name and AKA: __________________________________________________________________ Age: ______ Date of Birth: ______________________ Male: ___ Female: ___ Legal Settlement or Residence is: ________________________________________________________ ______________________________________________________ in ____________________ County, Ohio. Length of residence is: _______________________________________________. If the proposed ward/conservatee is living at an address different from the residence shown above , the address is ___________________________________________________________________________________. Name of person, other than the proposed ward/conservatee who may be contacted at the address where proposed ward/conservatee is living: Name ________________________________________________ Telephone __________________________ List any problems that proposed ward/conservatee may have in communicating: ___________________ ____________________________________________________________________________________ List any agencies, either private or public, who have knowledge of the proposed ward/conservatee, and may be aware of assistance in determining the need for guardianship/conservatorship: ______________ ____________________________________________________________________________________ INFORMATION CONCERNING NEED FOR GUARDIANSHIP: Describe briefly the basis for application: __________________________________________________ ____________________________________________________________________________________ I hereby petition the Court to be appointed guardian/conservator of foregoing proposed ward/conservatee and certify that all the information and statements contained in this application and attached exhibits are correct to the best of my knowledge and belief. ____________________________________________________________________________________ Signature of Attorney of Record ID# ____________________________________________________________________________________ Signature of Prospective Guardian/Conservator ____________________________________________________________________________________ Signature of Proposed Conservatee (Conservatorship only) I, ______________________, Attorney-at-law, hereby certify, that the within instrument was prepared and/or examined by me, and that the same, in my opinion, is correct and proper. PAGE 2 OF FORM 15-A ­ SUPPLEMENTAL GUARDIANSHIP/CONSERVATORSHIP INFORMATION REV 5/13/08 American LegalNet, Inc. www.FormsWorkFlow.com