PROBATE COURT OF ___________________________COUNTY, OHIO
_____________________, JUDGE
IN THE MATTER OF __________________________________________, AN ADULT
CASE NO. _______________________
NOTICE OF PETITION FOR COURT ORDERED
PROTECTIVE SERVICES ON AN EMERGENCY BASIS
[R.C. 5101.69]
TO:__________________________________________________________________________
Name of Adult, spouse, if any, if no spouse, adult children or next of kin, and guardian, if any, if their whereabouts are known.
_____________________________________________________________________________________________
You are hereby notified that on the _____ day of _________, 20 ____, the ____________County
Department of Job and Family Services filed a Petition for Court Ordered Protective Services to
be provided for the above named Adult without the Adult’s consent on the grounds that an
emergency exists and that the Department has been unable to obtain the consent of the Adult for
protective services to be given. A copy of the petition is attached hereto.
The Petition has been set for hearing in the ________________________ County Probate Court,
____________, Ohio located at ________________________ on the _____ day of
_____________, 20 _______at ______________ o’clock ______.M. The Adult may appear at
the hearing, may present, examine, and cross-examine witnesses, and present evidence to contest
the petition. The Adult is entitled to be represented by an attorney and, if found to be indigent,
the Adult may request an attorney to be appointed without cost.
Witness my signature and the seal of the Court
this _____ day of _____________, 20 _____.
______________________________________
Probate Judge
By:___________________________________
Deputy Clerk
FORM 23.3 – NOTICE OF PETITION FOR COURT ORDERED
PROTECTIVE SERVICES ON AN EMERGENCY BASIS
Eff. Date: January 1, 2010
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