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Pre-Placement Application 20.01 - Ohio
| Pre-Placement Application Form. This is a Ohio form and can be used in Adoption Probate Lucas County (Court Of Common Pleas) . |
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PROBATE COURT OF LUCAS COUNTY, OHIO JUDGE JACK R. PUFFENBERGER Pre-Placement Application Case No.: _____________________ Applicant_____________________________ Applicant________________________ ____ (Last, First, Middle) (Last, First, Middle) _____________________________________ __________________________________ __ Birthdate Place of Birth Birthdate Place of Birth _____________________________________ __________________________________ __ Race/Ethnic Background SS# Race/Ethnic Background SS# _____________________________________ __________________________________ __ Occupation Occupation _____________________________________ __________________________________ __ Address Phone # _____________________________________ __________________________________ __ City State Zip Country Directions for reaching the residence: _________________________________ ______________ ________________________________________________________________________ ______ ________________________________________________________________________ ______ Date of Marriage d Obtained (City, County, State) License Other Members of Household ___________________________ _______________ _____ __________________ Name Birthdate Sex Relation to Applicant ___________________________ _______________ _____ __________________ Name Birthdate Sex Relation to Applicant ___________________________ _______________ _____ __________________ Name Birthdate Sex Relation to Applicant ___________________________ _______________ _____ __________________ Name Birthdate Sex Relation to Applicant Has either applicant been married before? U Yes U No If divorced, when and where was the divorce obtained and identify which applicant. ____________________________ ________________________________________________________________________ ______ Have you ever applied to or adopted a child from any other source?U Yes U No If yes, what source, when and where? ____________________________________________________ LCPC Form 20.1 (page 1of 3) American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Has either applicant been convicted of a criminal offense?U Yes U No If yes, what was the offense? ______________________________________________________________________ Have you had treatment for a serious or chronic illness?U Yes U No Explain: _________ ________________________________________________________________________ ______ Have you ever received, or been advised to seek, mental health services?U Yes U No Explain: ______________________________________________________________ ________ Have you ever received, or been advised to seek, treatment for alcohol/substance abuse?U Yes U No Explain: ________________________________________________________ _______ Education _____________________________________ __________________________________ __ High School High School _____________________________________ __________________________________ __ Other Other _____________________________________ __________________________________ __ Present Employment _____________________________________ __________________________________ __ Employer Phone # Employer Phone # _____________________________________ __________________________________ __ Length Employed Salary Length Employed Salary Insurance _____________________________________ __________________________________ __ Total Life Face Value Total Life Face Value _____________________________________ __________________________________ __ Household Face Value Household Face Value _____________________________________ __________________________________ __ Medical M edical _____________________________________ __________________________________ __ Other Other _____________________________________ __________________________________ __ LCPC Form 20.1 (page 2 of 3) American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3List four references who have known you well (include some wh o know your home life) ______________________ __________________________ ___________ ____________ Name Address Telephone # Relationship ______________________ __________________________ ___________ ____________ Name Address Telephone # Relationship ______________________ __________________________ ___________ ____________ Name Address Telephone # Relationship ______________________ __________________________ ___________ ____________ Name Address Telephone # Relationship How long has the child lived in this home ____________________________________________ Is the father legal or putative ________________________________________ ______________ FOR RELATIVE ADOPTION ONLY: Relationship of Applicant(s) to Adoptee(s): __________________________________________ Adoptee(s) name(s) as it now appears on birth certificate ________________________________ ________________________________________________________________________ ______ Adoptee(s) name(s) U will remain the same U will be changed to _________________ ________________________________________________________________________ ______ Adoptee(s) date(s) of birth: _______________________________________________________ Applicant(s) understand that this docum is only an application and that additional ent information and documentation will be required.Applicant(s) understan d that this Court will require further investigation for purposes of conducting a Homestudy. _____________________________________ __________________________________ __ Applicant Applicant _____________________________________ Attorney of Record _____________________________________ Address _____________________________________ City State Zip _____________________________________ Phone # _____________________________________ Ohio Supreme Court Number LCPC Form 20.1 (page 3 of 3) American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com
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