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Statement Of Emergency Protective Placement GN-4000 - Wisconsin

Statement Of Emergency Protective Placement Form. This is a Wisconsin form and can be used in Guardianship Circuit Court Statewide .
 Fillable pdf Last Modified 6/3/2009
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FORM SUMMARY Name of Form: Form Number: Statement of Emergency Protective Placement GN-4000 Statutory Reference: Benchbook Reference: Purpose of Form: §55.135, Wisconsin Statutes GA-3 To state that an individual has been taken into custody for Emergency Protective Placement. Sheriff or police officer, fire fighter, guardian or authorized representative of the county department or an agency with which it contracts under §55.02(2), Wisconsin Statutes. Original to court. Copy to facility. A Petition for Protective Placement (GN-4040) shall be filed. A Petition for Guardianship (GN-3100) must be filed if there is no guardian. Modification; last update 07/01 Modified to comply with 2005 Wis. Acts 264, 387 and 388. Who completes it: Distribution of Form: Accompanying Forms: New Form/Modification: Modifications: Comments: About this form: PLEASE BE INFORMED: This form is based on unofficial text from Revisor of Statutes. This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. 10/05/2006 Page 1 American LegalNet, Inc. www.FormsWorkflow.com For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Amended IN THE MATTER OF Statement of Emergency Protective Placement Case No. Date of Birth 1. I am: a sheriff or police officer. a fire fighter. a guardian. an authorized representative of the county department or an agency with which it contracts under §55.02(2). 2. It appears probable that the individual is so totally incapable of providing for the individual's own care or custody as to create a substantial risk of serious physical harm to the individual or others as a result of developmental disabilities, degenerative brain disorder, serious and persistent mental illness or other like incapacities if not immediately placed in an appropriate medical or protective placement facility. The specific factual information that is the basis for the emergency protective placement, based on personal See attached observation or a reliable report by a person identified to me, is as follows: 3. A petition for protective placement is being filed with this statement. A petition for guardianship is also being filed unless: A. The individual is currently under guardianship or B. The individual is a minor who is alleged to be developmentally disabled. 4. The individual was detained at Name of Facility , on Date , at Time am. City County pm. State Zip code Subject's Street Address Signature of Person Making Placement Name of Department and Address Name Printed or Typed Telephone Number GN-4000, 10/06 Statement of Emergency Protective Placement §55.135, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material
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