PROBATE COURT OF FAIRFIELD COUNTY, OHIO Steven O. Williams,

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                               PROBATE COURT OF FAIRFIELD COUNTY, OHIO
                                                     Steven O. Williams, Judge

In the Matter of the Placement of:_______________________________________________________________________
                                                             (Child's Name After Adoption)
Case No: ______________________                                              Date:____________________________


                     APPLICATION FOR PLACEMENT OF A CHILD TO BE ADOPTED
                                                (As per Section 5103.16 of the Ohio Revised Code)


                                           ADOPTING FATHER'S INFORMATION


Name (Last, First, Middle)                                Birthdate                      Age                 Birthplace

Current Address (Street, City, State, Zip Code)

Education (Highest grade completed or degree earned)                          Name of School/University                                Date

Race                      Ethnic Background                         Religious Denomination                            Social Security Number

Name and Address of Current Employer                                Occupation/Position Held                          Length of Employment

Name of Previous Employer (1)                                                                       Dates of Employment

Name of Previous Employer (2)                                                                       Dates of Employment

Current Marital Status:      Single         Married        Divorced       Widowed          # Marriages                # Divorces

List    Dates                       Places                                    Full Name of Spouses of ALL Marriages




List       Termination                 Places                    How                Full Name of Spouses of ALL Previous Marriages
             Dates                                            Terminated




Physical Description:     Height:                         Weight:                        Hair:                Eyes:            Skin:

Description of Personality:



Describe personal interests, hobbies, group memberships




                                                FORM 19.4 - ADOPTING PARENTS' INFORMATION
                                         ADOPTING MOTHER'S INFORMATION


Name (Last, First, Middle)                            Birthdate                    Age                 Birthplace

Current Address (Street, City, State, Zip Code)

Education (Highest grade completed or degree earned)                     Name of School/University                                Date

Race                       Ethnic Background                    Religious Denomination                           Social Security Number

Name and Address of Current Employer                            Occupation/Position Held                         Length of Employment

Name of Previous Employer (1)                                                               Dates of Employment

Name of Previous Employer (2)                                                               Dates of Employment

Current Marital Status:       Single      Married      Divorced      Widowed         # Marriages                # Divorces

List    Dates                        Places                              Full Name of Spouses of ALL Marriages




List         Termination             Places                  How             Full Name of Spouses of ALL Previous Marriages
               Dates                                      Terminated




Physical Description:      Height:                    Weight:                      Hair:                 Eyes:            Skin:

Description of Personality:



Describe personal interests, hobbies, group memberships




Petitioner                                                                                  Petitioner

____________________________                                                                ____________________________
Phone Number (include area code)                                                            Phone Number (include area code)