Pre-Placement Application {20.1}

PROBATE COURT OF LUCAS COUNTY, OHIO JUDGE JACK R. PUFFENBERGER Pre-Placement Application Case No.: _____________________ Applicant_____________________________ (Last, First, Middle) _____________________________________ Birthdate Place of Birth _____________________________________ Race/Ethnic Background _____________________________________ Occupation _____________________________________ Address _____________________________________ City State Zip _____________________________________ E-Mail Address Directions for reaching the residence: ______________________________________________________________________________ ______________________________________________________________________________ Date of Marriage Licensed Obtained (City, County, State) Other Members of Household ___________________________ Name ___________________________ Name ___________________________ Name ___________________________ Name Applicant____________________________ (Last, First, Middle) ____________________________________ Birthdate Place of Birth ____________________________________ Race/Ethnic Background ____________________________________ Occupation ____________________________________ Phone # ____________________________________ County ____________________________________ E-Mail Address _______________ Birthdate _______________ Birthdate _______________ Birthdate _______________ Birthdate _____ Sex _____ Sex _____ Sex _____ Sex __________________ Relation to Applicant __________________ Relation to Applicant __________________ Relation to Applicant __________________ Relation to Applicant Has either applicant been married before? Yes 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? Yes No If yes, what source, when and where? ____________________________________________________ LCPC Form 20.1 (page 1of 3) Revised 2/4/2016 American LegalNet, Inc. www.FormsWorkFlow.com Case No.: _____________________ Has either applicant been convicted of a criminal offense? Yes No If yes, what was the offense? ______________________________________________________________________ Have you had treatment for a serious or chronic illness? Yes No Explain: ______________________________________________________________________________ Have you ever received, or been advised to seek, mental health services? Yes No Explain: ______________________________________________________________________ Have you ever received, or been advised to seek, treatment for alcohol/substance abuse? Yes No Explain: _______________________________________________________________ ____________________________________ High School Other: Education _____________________________________ High School Other: Present Employment _____________________________________ Employer Phone # _____________________________________ Length Employed Salary Insurance _____________________________________ Total Life Face Value _____________________________________ Household Face Value _____________________________________ Medical Other: ____________________________________ Employer Phone # ____________________________________ Length Employed Salary ____________________________________ Total Life Face Value ____________________________________ Household Face Value ____________________________________ Medical Other: LCPC Form 20.1 (page 2 of 3) American LegalNet, Inc. www.FormsWorkFlow.com Case No.: _____________________ List four references who have known you well (include some who 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) will remain the same will be changed to: ______________________________________________________________________________ Adoptee(s) date(s) of birth: _______________________________________________________ Applicant(s) understand that this document is only an application and that additional information and documentation will be required. Applicant(s) understand that this Court will require further investigation for purposes of conducting a Homestudy. _____________________________________ Applicant _____________________________________ Attorney of Record _____________________________________ Address _____________________________________ City State Zip _____________________________________ Phone # _____________________________________ Ohio Supreme Court Number LCPC Form 20.1 (page 3 of 3) American LegalNet, Inc. www.FormsWorkFlow.com ____________________________________ Applicant