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PROBATE COURT OF CLARK COUNTY, OHIO
Richard P. Carey, Judge
In the Matter of:_____________________________________________________________________
Case No._______________________
APPLICATION TO PAY OR DELIVER ESTATE OF A MINOR WITHOUT
APPOINTMENT OF A GUARDIAN
[R.C. 2111.05]
Applicant states that __________________________, is a minor, born ______________________________
residing at _______________________________________________________________________________
in this County. Said minor is entitled to receive assets in the amount of $___________________, which
amount does not exceed twenty-five thousand dollars ($25,000), further described as follows:
________________________________________________________________________________________
Applicant states that there is no legal guardian of the estate.
A copy of the birth certificate is attached.
The names and addresses of the minor's parent and natural guardians are:
Mother: _________________________________________________________________________________
Father: _________________________________________________________________________________
If the parents are deceased, disabled, or their whereabouts are unknown, _____________________________
who resides at ____________________________________________________________________________
is the person by whom the minor is maintained.
Applicant further asks that the funds be: [check one]
**
(1) delivered to the minor.
**
(2) delivered to the custodian of the minor.
**
(3) delivered to the natural guardian of the minor.
**
(4) delivered to the executive director responsible for children services.
(5) deposited in a financial institution authorized to receive fiduciary funds for the minor.
** For 1, 2, 3 or 4 attach a narrative statement setting forth the reasons.
The applicant acknowledges that he or she may be subject to criminal penalties for
improper conversion of any property held on behalf of the minor
Applicant
Attorney for Applicant
Typed or Printed Name
Typed or Printed Name
Address:
Address:
Phone Number (include area code)
Phone Number (include area code)
Attorney Registration No.
FORM 16.0A - APPLICATION TO PAY OR DELIVER ESTATE OF MINOR WITHOUT
APPLICATION OF GUARDIAN
4/26/2010