FORM SUMMARY Name of Form Form Number Petition Objecting to Transfer of Protective Placement GN-4350 Statutory Reference Benchbook Reference Purpose of Form §55.15(6), Wisconsin Statutes GA-3 Petition the court for a hearing to object to the transfer of individual under protective placement. Petitioner or attorney. Original to court. Who Completes It: Distribution of Form Accompanying Forms: New Form/Modification: Modifications: Comments: About this Form: Modification, last update 01/06. Modified to comply with 2005 Wis. 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 Petition Objecting to Transfer of Protective Placement Case No. Date of Birth 1. I am the: individual under protective placement. individual's guardian. individual's attorney. other interested person: 2. I object to the transfer because: the transfer is to a unit for the acutely mentally ill. the transfer is to a locked unit without a specific finding from the court as to the need. the individual has developmental disabilities and the transfer is to an intermediate facility or nursing facility without development of a community plan or a community plan being furnished to the county department or agency and to the individual's guardian. the transfer is not to the least restrictive environment or in the least restrictive manner consistent with the needs of the individual under protective placement or the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds. the transfer is to an intermediate facility or nursing facility that is not in the most integrated setting that enables an individual to interact with persons without developmental disabilities to the fullest extend possible. the protective placement is not in the best interest of the individual under protective placement. See attached. Other: 3. I request the court appoint a guardian ad litem and conduct a hearing within 10 days after the filing of this petition to determine whether to approve the proposed transfer or emergency transfer. Subscribed and sworn to before me on ____________________________________________ Signature of Petitioner Notary Public, State of Wisconsin Name Printed or Typed My commission expires: Address Name of Attorney Address Telephone Number Bar Number Original: Court Copies: Petitioner Guardian County department or agency with which it contracts. Individual under protective placement Protective placement facility Individual's attorney, if any GN-4350, 10/06 Petition Objecting to Transfer of Protective Placement §55.15(6), Wisconsin Statutes American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material.