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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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For Official Use STATE OF WISCONSIN, CIRCUIT COURT, IN THE MATTER OF Amended COUNTY 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 a developmental disability, 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 observation or a reliable report by a person identified to me, is as follows: See attached 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 have a developmental disability. 4. The individual was detained at Name of Facility , , at am. Time on Date pm. Subject's Street Address City County State Zip code Signature of Person Making Placement Name of Department and Address Name Printed or Typed Telephone Number Distribution: 1. Original ­ Court 2. Individual 3. Facility 4. Guardian ad Litem 5. Department 6. Other: GN-4000, 01/09 Statement of Emergency Protective Placement §55.135, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material American LegalNet, Inc. www.FormsWorkFlow.com
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