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Notice Of Transfer Of Protective Placement GN-4340 - Wisconsin
| Notice Of Transfer Of Protective Placement 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 Notice of Transfer of Protective Placement GN-4340 Statutory Reference Benchbook Reference Purpose of Form §55.15(5), Wisconsin Statutes GA-3 Notice of transfer and placement of individual under order for protective placement. Guardian, county department, Wisconsin Dept. of Health and Family Services, or protective placement facility. Original to court. Who Completes It: Distribution of Form Accompanying Forms: New Form/Modification: Modifications: Comments: About this Form: Modification, last update 01/06. Updated to comply with 2005 Wis. Stats. Acts 264, 387 and 388. 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. Date: 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 Notice of Transfer of Protective Placement Date of Birth Case No. 1. The placement of the individual under protective placement is being transferred by: guardian. county department or agency with which it contracts. the Wisconsin Department of Health and Family Services. protective placement facility. 2. This transfer is being made: between protective placement units. between protective placement facilities. from a protective placement unit to a medical facility. This is not a transfer to any facility for which commitment procedures are required under Chapter 51, Wisconsin Statutes. 3. NON-EMERGENCY TRANSFER. This Notice of Transfer is being provided for a non-emergency transfer 10 days prior to the transfer to the court and to each of the persons and entities specified above who did not initiate the transfer. The guardian will provide written consent prior to the transfer. The county department will provide written consent prior to the transfer if this transfer is to a facility that is more costly to the county. The individual under a protective placement, the individual's attorney, if any, or other interested person has the right to petition the court for a hearing on the transfer. 4. EMERGENCY TRANSFER. An emergency has made it impossible to provide prior notice or obtain prior written consent of the guardian. This notice of transfer is being provided for an emergency transfer immediately upon transfer to each of the persons and entities specified above who did not initiate the transfer, and to the court that ordered the protective placement within a reasonable time, not to exceed 48 hours from the time of transfer. The individual under a protective placement, the individual's guardian, the individual's attorney, if any, or any other interested person has the right to file a petition with the court objecting to the emergency transfer. 5. This transfer will occur or has occurred at (am) (pm) on , 20 . TRANSFER FROM: (Placement unit Name, address, telephone number) TRANSFER TO: (Placement unit Name, address, telephone number) Signature of Person or Entity Representative initiating transfer Original: Court Copies: Guardian. County department or agency with which it contracts. The Wisconsin Dept. of Health and Family Services. Protective Placement facility. Name Printed or Typed Date GN-4340, 10/06 Notice of Transfer of Protective Placement §55.15(5), Wisconsin Statute American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material.
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