COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.PROBATE COURT OF COUNTY, OHIOERIECalendar No.IN THE MATTER OF THE GUARDIANSHIP OF Case No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)DocketPageSTATEMENT OF EXPERT EVALUATION(R.C. 2111.01(D)):. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .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 Honorable,located at County of(R.C. 2111.49(A)(1)(i).)o'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 roomDefinition 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. This Statement of Evaluation is for: Guardianship Application. (To be completed by a Licensed Physician or 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 date of the report. (R.C. 2111.49(A)(1)(i).) 2. Statement completed by: (please type or print)NameAddressYour 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.PhoneWho is a:, one of the Justices of the Licensed Physician Licensed Clinical Psychologist Licensed Social WorkerCourt in Witness, Honorableday of, 20 County, Mental Retardation Team3. Following is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward.(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:4. Is the prospective ward mentally impaired?No Yes Mobile Tel. No.:17.1 STATEMENT OF EXPERT EVALUATIONAmerican LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. A. Is there observed or reported evidence of mental impairment?:::::::Index No.Yes No Describe:Calendar No.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. Is there observed or reported evidence of physical impairment?THE PEOPLE OF THE STATE OF NEW YORK TOYes No Describe:GREETINGS:B. If reported name source: 8. Can the prospective ward conduct business affairs without the aid of a guardian?WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Yes No Comments: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 room9. Can the prospective ward properly care for himself without the aid of a guardian?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.Yes No Comments:, one of the Justices of the10. (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 .Court in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)ADDITIONAL COMMENTSAttorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:I certify that I have evaluatedfor the purpose of guardianship.Mobile Tel. No.:EvaluatorDate of EvaluationAmerican LegalNet, Inc. www.USCourtForms.com
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