Ohio Probate Form - Petition For Protective Services
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2PROBATE COURT OF ___________________________COUNTY, OHIO
_______________________________, JUDGE
IN THE MATTER OF __________________________________________, AN ADULT
CASE NO. _______________________
PETITION FOR PROTECTIVE SERVICES
[R.C. 5101.65]
1.
Petitioner, _____________________________, is an authorized provider of adult
protective Services pursuant to R.C. 5101.60, et seq. and has received a report that the above
named Adult is in need of protective services.
2.
The Adult, _____________________________, residing at________________________
____________________________is ________years of age, with a date of birth of ___________
and is alleged to be an incapacitated person subject to abuse, neglect, or exploitation.
3.
The specific facts alleging the abuse, neglect, or exploitation are:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4.
The proposed protective service plan including the least restrictive placement, if
applicable, is as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5.
The Adult and the following persons are required to receive notice pursuant to R.C.
5101.66:
Name
Address
Relationship to Adult
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
FORM 23.0 – PETITION FOR PROTECTIVE SERVICES
Eff. Date: January 1, 2010
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