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Petition For Protective Placement Protective Services GN-4040 - Wisconsin
| Petition For Protective Placement Protective Services Form. This is a Wisconsin form and can be used in Guardianship Circuit Court Statewide . |
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FORM SUMMARY Name of Form: Form Number: Petition for Protective Placement/Protective Services GN-4040 Statutory Reference: Benchbook Reference: Purpose of Form: Who Completes It: Distribution of Form: Accompanying Forms: New Form/Modification: Modifications: Comments: §46.279, Chapter 54 and 55, Wisconsin Statutes GA-3 Initiate a protective placement and/or protective services. Petitioner or attorney. Original to court. Modification, last update 06/06. Modified to comply with 2005 Wisconsin Acts 264, 387 and 388. Interested parties and parties entitled to notice can be found in §§55.01(4) and 55.09(1), (2), Wis. Statutes. 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. About this form: Date: 10/05/2006 Page 1 American LegalNet, Inc. www.FormsWorkflow.com For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Petition for Protective Placement Protective Services Case No. Date of Birth UNDER OATH, I STATE THAT: 1. I am interested as: the Wisconsin Department of Health and Family Services. the county department or an agency with which the county department contracts. the guardian. an interested person: . 2. This petition is filed in: the county of residence of the individual. the county in which the individual is physically present. Other: 3. The residence of the individual is in and the individual's post-office address is: County, State of , . 4. I have exercised due diligence to locate all interested parties. The names and post office addresses of all See attached. interested parties and all others entitled to notice are as follows: NAME RELATIONSHIP POST-OFFICE ADDRESS 5. The individual, if married, does does not have children not of the current marriage. 6. The individual: does not have a current, valid financial durable power of attorney does Name, address and phone: activated. does not have a current, valid power of attorney for health care does Name, address and phone: activated. does not have other advance planning to avoid protective placement. does If the above-named powers of attorney or advanced planning exist, protective placement is still necessary because: . See attached. GN-4040 10/06 Petition for Protective Placement/Protective Services Page 1 of 3 §46.279, Chapter 54 and 55, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material. GN-4040 Petition for Protective Placement/Protective Services Case No. Page 2 of 3 7. A. A petition for permanent guardianship is being filed. B. A guardian has been appointed: in this county. in another county in this state (Name of guardian and county where appointed) in another state (Name of guardian and state where appointed) and a separate petition for receipt and acceptance of a foreign guardianship is being filed to accompany this petition. 8. The name and post-office address of the person or institution, if any, that has care and custody of the individual or the facility, if any, that is providing care to the individual is: Phone Number: Name: Post-office Address: Type of facility: community based residential facility No Yes Is this facility licensed for 16 or more beds? nursing facility center for developmentally disabled intermediate facility Other: 9. I am requesting protective placement and/or protective services for the individual, based upon personal knowledge of the individual, and I state that: A. The individual is eligible for protective placement because the individual: has attained the age of 18. is alleged to be developmentally disabled and has attained the age of 14. B. A petition for adult protective placement is being initiated not more than 6 months prior to the individual's birthday at which the individual first becomes eligible for placement. C. The individual has been adjudicated incompetent in Wisconsin more than 12 months before the filing of this petition for protective placement and/or protective services and a court review is required of the finding of incompetency. D. The non-resident individual has a need for protective placement and/or protective services and a separate petition to transfer a foreign guardianship has been filed whether the individual is present in the state or not. E. A comprehensive evaluation and community plan, if required, and recommendation for placement by the will be filed. A copy of the comprehensive is being filed. appropriate board or designated agency evaluation and any independent comprehensive evaluation will be provided to the individual's guardian, agent under any activated health care power of attorney, guardian ad litem, the individual and the individual's attorney at least 96 hours in advance of the hearing to determine protective placement or protective services. FOR PROTECTIVE PLACEMENT. 10. A. The individual needs protective placement and meets the standards for protective placement specified in §55.08 (1), Wisconsin Statutes as follows: 1. The individual has a primary need for residential care and custody. 2. Except in the case of a minor that is age 14 or older, who is alleged to be developmentally disabled, the individual has either been adjudicated to be incompetent by a circuit court or a petition for guardianship has been submitted on the minor's behalf; serious and persistent degenerative brain disorder developmental disabilities 3. As a result of other like incapacities, the individual is so totally incapable of providing for his or her mental illness own care or custody as to create a substantial risk of serious harm to himself or herself or others. Serious harm may be evidenced by overt acts or acts of omission. 4. The individual has a disability that is permanent or likely to be permanent. GN-4040, 10/06 Petition for Protective Placement/Protective Services Page 2 of 3 §46.279, Chapter 54 and 55, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material. GN-4040 Petition for Protective Placement/Protective Services Case No. Page 3 of 3 B. The specific facts and details of how the individual me
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