COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.PROBATE COURT OFCOUNTY, OHIOJUDICIAL 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:Definition of incompetent [ O.R.C. 2111.01 (D)): Incompetent means any person who is so mentally impaired as a result of a mental or physical illness or disability, or mental retardation, or as a result of chronic substance abuse, that the person is incapable of taking proper care of the person's self or property or fails to provide for the person's family or other persons for whom the person is charged by law to provide , or any person confined to a correctional 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.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 of1.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 thre months of date of the report. 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 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.2.Statement completed by: (please type or print), one of the Justices of theName:Address: Phone Who is a: Licensed PhysicianCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below) Licensed Clinical Psychologist Licensed Social Worker Mental Retardation TeamAttorney(s) for3.Following is my diagnosis/assessment of the mental and physical capacity, and the functioning level of the prospective ward. Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:FORM 17.1 -STATEMENT OF EXPERT EVALUATION1/1/98American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.CASE NO.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)4.Is the prospective ward mentally impaired?Yes No5.A. Is there observed or reported evidence of mental impairment?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yes No Describe: B. If reported, name source: THE PEOPLE OF THE STATE OF NEW YORK TO6.If the prospective ward is mentally impaired, what is the cause? 7.A. Is there observed or reported evidence of physical impairment?Yes No Describe: B. If reported, name source: GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable8.Can the prospective ward conduct business affairs without the aid of a guardian?,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 roomYes No Comments: 9.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: 10.(TO BE COMPLETED IF SUBMITTED WITH A GUARDIAN'S REPORT) In my opinion, the guardianship should be: Continued Terminated , one of the Justices of the11.(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. AddressI certify that I have evaluated for the purpose of guardianship. Date of EvaluationTelephone No.: Facsimile No.: E-Mail Address:EvaluatorMobile Tel. No.:FORM 17.1 STATEMENT OF EXPERT EVALUATIONAmerican LegalNet, Inc. www.USCourtForms.com
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