COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

BACKGROUND DISCLOSURE STATEMENT
FOR PARENTING COORDINATION APPOINTMENT LIST

Name:	Telephone:
Attorney Number.	Cell Phone:
Business Address:	FAX:
Email:

A “YES” RESPONSE TO ANY QUESTION LISTED BELOW MUST BE SUPPLEMENTED WITH A THOROUGH EXPLANATION ON A SEPARATE SHEET OF PAPER.

BACKGROUND	YES	NO

1.	Have you been cited or convicted of a moving traffic violation in the past 5 years?

2.	Have you had any traffic violations involving alcohol or drugs in the past 5 years?

3.	Have you ever been convicted of a violation of law other than a minor misdemeanor or

moving violation as an adult?

4.	Have you ever been charged with a crime involving a minor?

5.	Have you ever committed an act that resulted in a child being adjudicated abused or neglected?

6.	Have you been a party to any civil litigation related to your profession in the past 5 years?

7.	Have you declared bankruptcy in the last 10 years?

8.	Do you have any condition or impairment which currently affects, or if untreated could affect,

your ability to competently practice your profession?

CONDUCT

Have you ever been subject to a contempt action in any court or found in contempt by a judge?

Have you ever been disbarred, suspended, censured, or otherwise reprimanded or disqualified as a

member of the legal profession, another profession, or as a holder of public office?

Have you ever been the subject of any charges, complaints, or grievances concerning your

conduct as a member of the legal profession, another profession, or as a holder of public office?

Has any surety on any bond, on which you were the principal, been required to pay any money

on your behalf in the past 5 years?

Have sanctions been entered against you, or have you been disqualified from participating

in any case in the past 5 years?

6.	Are you aware of any complaints filed against you with any Bar Association in the past 10 years?	a. If so, are all complaints resolved?

7.	Are you currently in good standing with the Ohio Supreme Court?

I, the undersigned applicant, have read the foregoing background disclosure statement and have answered all questions truthfully and completely. I understand that failure to answer any question completely and honestly will result in denial or loss of eligibility to serve as a parenting coordinator in the Hamilton County Court of Domestic Relations, and may result in a referral to the City Attorney, County Prosecutor or the Cincinnati Bar Association for appropriate action. I further understand that I have the ongoing duty to supplement my answers to the questions herein.

Signature of Applicant

Subscribed and sworn to or affirmed before me this ______ day of	,	.	month year

Notary Public

This form is for review purposes only prior to your approval as a Parenting Coordinator.
It will be destroyed once the approval process is complete.