Petitioners Account {18.9}

PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE ADOPTION OF: (Name after Adoption) CASE NO.: PETITIONER'S ACCOUNT [R.C. 3107.055] PRELIMINARY ESTIMATE ACCOUNTING (To be filed not later than date petition filed) FINAL ACCOUNTING (To be filed not later than 10 days prior to date of final hearing) This accounting specifies all disbursements of anything of value the petitioner, a person on the petitioner's behalf, and the agency or attorney made and has agreed to make in connection with the minor's permanent surrender under division (B) of Section 5103.15 of the Revised Code, placement under Section 5103.16 of the Revised Code, and adoption under Chapter 3107. (Attach extra sheets if necessary) DATE PHYSICIAN NAME AND ADDRESS DISBURSEMENTS MADE OR AGREED TO BE MADE ACTUAL COSTS HOSPITAL/MEDICAL FACILITY ATTORNEY ACTUAL COST TO THE ATTORNEY AGENCY ACTUAL COST TO THE AGENCY MAINTENANCE AND MEDICAL CARE REQUIRED UNDER R.C. 5103.15 EXPENSES PURSUANT TO R.C. 3107.055(C)(9) FOSTER CARE GUARDIAN AD LITEM COURT COSTS ALL OTHER DISBURSEMENTS TOTAL FORM 18.9 ­ PETITIONER'S ACCOUNT Page 1 of 2 Amended: September 1, 2011 Disregard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.: [Reverse of Form 18.9] CERTIFICATION OF PETITIONER'S ACCOUNT The undersigned certifies this ____ day of ____________________________, 20___, that this accounting is true and accurate. _________________________________________ Attorney or Agency _________________________________________ Typed or Printed Name _________________________________________ Address _________________________________________ City State Zip Code _________________________________________ Telephone Number (include area code) The petitioner has reviewed this accounting and attests to it's accuracy this _____ day of ____________________, 20____. _________________________________________ Petitioner _________________________________________ Petitioner FORM 18.9 ­ PETITIONER'S ACCOUNT Page 2 of 2 Amended: September 1, 2011 Disregard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com