Statement Of Expert Evaluation {17.1}

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)IN THE MATTER OF THE GUARDIANSHIP OF CASE NO.: STATEMENT OF EXPERT EVALUATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableDefinition of Incompetent (R.C. 2111.01 (D): Incompetent means any person who is so mentally impaired as a result of a physical or mental illness or disability, or retardation, or as a result of chronic substance abuse, that he is incapable of taking proper care of himself or his property or fails to provide for his family or other persons for whom he is charged by law to provide, or any person confined to a penal institution within this State. The Statement of Evaluation does not declare the prospective ward competent or incompetent, but is evidence to be considered by the Court. The fee for completing this evaluation WILL NOT be paid by the Court. Each evaluator should secure payment from the Applicant/Guardian. 1.,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.This Statement of Evaluation is for: Guardianship Application. (To be completed by a Licensed Physician, Licensed Clinical Psychologist, and attached to the Application). Guardian's Report. (Evaluation and Statement by a Licensed Physician, Licensed Clinical Psychologist, Licensed Social Worker, or Mental Retardation Team to be completed within three months of the date of the report. R.C. 2111.49 (A) (1) (I)). 2.Statement completed by: (please type or print) Name Address Phone Who is a:, one of the Justices of theCourt in Witness, Honorableday of, 20 County, Licensed Licensed Clinical PhysicianPsychologist Licensed Social Mental Retardation Worker(Attorney must sign above and type name below)Team3.Attorney(s) forFollowing is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward. 4.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Is the prospective ward mentally impaired?«HE28/ 20-Mobile Tel. No.:No Yes REV 4/8/02PAGE 1 OF FORM 17.1 STATEMENT OF EXPERT EVALUATIONAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. A.:::::::Index No.Calendar No.Is there observed or reported evidence of mental impairment? Yes No Describe: JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)B.If reported, name source: 6.If the prospective ward is mentally impaired, what is the cause? 7. A.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOIs there observed or reported evidence of physical impairment? Yes No Describe: B.GREETINGS:If reported, name source: 8.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Can the prospective ward conduct business affairs without the aid of a guardian? Yes No Comments: 9.located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomCan the prospective ward properly care for himself without the aid of a guardian? Yes No Comments: 10.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.(TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN'S REPORT) In my opinion, the guardianship should be:Continued Terminated .11.(TO BE COMPLETED IF SUBMITTED WITH AN APPLICATION FOR GUARDIANSHIP) In my opinion, the application for guardianship: Should be granted Should not be granted ., one of the Justices of theCourt in Witness, Honorableday of, 20 County,ADDITIONAL COMMENTS(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressI certify that I have evaluated for the purpose of guardianship.Date of Evaluation Evaluator Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:REV 4/8/02PAGE 2 OF FORM 17.1 STATEMENT OF EXPERT EVALUATIONAmerican LegalNet, Inc. www.USCourtForms.com</document>