Applicant's Supplemental Information Form - Fairfield County Court of Common Pleas (Fillable)

Guardianship of Case number Full legal name Also known as Age Date of birth Married Not married Have you ever filed bankruptcy yes Have you ever filed bankruptcy no Felony question yes Felony question no Felony charge row 1 Date of conviction row 1 Place city and state row 1 Felony charge row 2 Date of conviction row 2 Place city and state row 2 Felony charge row 3 Date of conviction row 3 Place city and state row 3 Currently employed yes Currently employed no Occupation Full time Part time name of employer employer address employer city employer state employer zip employer phone Sufficient time to devote to responsibilities yes Sufficient time to devote to responsibilities no Served as a gaurdian yes Served as a gaurdian no currently serving as a gaurdian yes currently serving as a gaurdian no

Case number In how many cases are you currently serving as guardian How many of those cases are in Fairfield County Ohio Ever sanctioned yes Ever sanctioned no Special training skills or experience line 1 Special training skills or experience line 2 Special training skills or experience line 3 Met with proposed ward within 30 days yes Met with proposed ward within 30 days no Power of Attorney Health Care Power of Attorney Problems using documents yes Problems using documents no Describe circumstances line 1 Describe circumstances line 2 Describe circumstances line 3 Physician Attorney Caregiver Landlord Do you owe ward money yes Do you owe ward money no Does ward owe you money yes Does ward owe you money no No potential conflicts of interest exist Potential conflict line 1 Potential conflict line 2 Potential conflict line 3 Attorney typed or printed name Attorney registration number Applicant typed or printed name