Form 26.0 - Petition For Involuntary Treatment For Alcohol And Other Drug Abuse Page 3

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CASE NO. __________
GUARANTEE OF PAYMENT
[R.C. 5119.93(D)(2)]
Pursuant to R.C. 5119.93(D)(2), either the Petitioner or other authorized person (spouse,
relative or guardian) shall guarantee any and all costs and fees for examinations, hearing cost
and treatment for the Respondent for alcohol and other drug abuse as may be herein after
ordered by the Court. The GUARANTEE below shall be completed by either the Petitioner or
other authorized person.
By my signature below, I do hereby assume responsibility for and GUARANTEE PAYMENT
FOR ALL COSTS incurred on behalf of Respondent for all alcohol and other drug abuse
treatment, including, but not limited to, initial examination and transportation costs, as
hereinafter ordered by the Court.
_____________________________________
____________________
Signature
Date
_____________________________________
Name (Please Print)
_____________________________________
Relationship to Respondent (Petitioner, Spouse, Relative or Guardian)
__________________________________________________________________________
Complete Billing Address
________
______________
__
Sworn before me and signed in my presence on
of
, 20
____________________________________________________
Notary Public
Print Form
FORM 26.0 - PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE
PAGE 3
Effective Date: July 1, 2016

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