Fill and Sign the 3150 Written Notice of Rights Due to Incompetency Revised 5 Form

GN-3160, 02/16 Report of Guardian ad Litem (Guardianship Due to Incompetency) §§54.40, 54.42 , 54.44 and 55.10, W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 1 of 4 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Amended Report of Guardian ad Litem (Guardianship Due to Incompetency) Date of Birth Case No. I am the court appointed Guardian ad Litem for the above named individual and report to the court that I h ave completed the following duties (except as noted in the “Additional Comments” section at the end of this report) an d make the following report and recommendations: GENERAL DUTIES 1. INTERVIEWED INDIVIDUAL AND ADVISED INDIVIDUAL OF RIGHTS AND PROCEDURE . On [Date ] at [Place] , I interviewed individual and explained to the individual the contents of the petition, the app licable hearing procedure, the right to counsel, and the right to request or continue a limited guardianship. I advised individual, both orally and in writing o f that person’s right: to be present at the hearing; to counsel, including when a lawyer can be appointed; to an independent medical or psychological exami nation on the issue of competency (at county expense if the person is indigent); to a jury trial; and to appeal. 2. INTERVIEWED PROPOSED GUARDIAN(S) I interviewed the proposed guardian, proposed stand-by guardian, if any, and any other person s eeking appointment as guardian. 3. REVIEWED ADVANCE PLANNING I have reviewed any power of attorney for health care under ch.155, any durable financial power of attorney under ch. 243 executed by the individual, any other advance planning for financial and health care decision making in which the individual had engaged. 4. INTERVIEWED AGENT I have interviewed any agent appointed by the individual under any document specified above. 5. RECEIVED NOTICE OF HEARING AND COPIES OF REPORTS I have received proper notice of the hearing and copies of the physician’s and/or psycholog ist’s reports. If protective placement is being requested, I have received a copy of the comprehensive evaluation and , if applicable, the plan for home or community-based care. 6. PROVIDED NOTIFICATIONS I have notified the petitioner or petitioner’s counsel ( if any) of the information contained below. I have also notified the appointed guardian (if any) of the duty to be present at and right to participat e in the hearing, to present and cross-examine witnesses, to receive a copy of any comprehensive evaluation, and t o secure and present a report on an independent evaluation. REPORT AND RECOMMENDATIONS 7. OBJECTIONS The individual: does not does object to a finding of incompetency. does not does object to the proposed or present placement. does not does object to the recommendation of the guardian ad litem. is not is ambiguous on these matters. Report of Guardian ad Litem (Guardianship Due to Incompetency) Page 2 of 4 Case No. GN-3160, 02/16 Report of Guardian ad Litem (Guardianship Du e to Incompetency) §§54.40, 54.42 , 54.44 and 55.10, W isconsin Sta tutes This form shall not be modified. It may be supplemented with additional mater ial. Page 2 of 4 8. ADVERSARY COUNSEL Adversary counsel is not is requested by the individual. Adversary counsel is not is recommended. 9. JURY TRIAL A jury trial is not demanded. is demanded. 10. INDIVIDUAL’S ATTENDANCE Regarding the individual’s attendance at the hearing: it is my opinion the individual can attend the hearing in court. I waive the individual’s attendance after considering the ability of the individual to understand and meaningfully participate, the effect of the individual’s attendance on his/her physical or psychological health in relation to the importance of the proceedings and the individual’s express ed desires. I certify the individual is unable to attend for these specific reasons: the individual is unable to attend the hearing in court because of residency in a nursing home or other facility, physical inaccessibility, or a lack of transportation; and the indiv idual, advocate counsel, other interested person, or I request that the court hold the hearing in a place where the individual can att end. Specify location requested: 11. ADDITIONAL EVALUATIONS Additional medical, psychological or other evaluation is not is requested. Specify evaluation requested and reason: . 12. ADVANCED PLANNING My report to the court is that the individual’s advance planning is is not adequate to preclude the need for guardianship: . 13. BEST INTERESTS OF INDIVIDUAL Based on my investigation, I recommend that the court find that the individual is substanti ally: capable of caring for himself/herself. incapable of caring for himself/herself. capable of managing his/her property. incapable of managing his/her property. 14. GUARDIAN OF THE PERSON A. Rights to be removed in full. If removed, these rights may not be exercised by any person. I recommend that the court declare the individual has incapacity to exercise the following rights: (1) execute a will. (2) serve on a jury. (3) register to vote or to vote in an election. B. Rights to be removed in full or exercised by individual only with consent of Guardian of Person. I request that the court declare the individual has incapacity to exercise the following rights: Ward may not exercise this right. Remove right in full. Ward may exercise only with the consent of the Guardian of the Person. (1) consent to marriage. (2) apply for an operator’s/driver’s license. (3) apply for a fishing license. (4) apply for a license under Ch. 29, W is. Stats., other than fishing. (5) apply for a credential under §440.01(2), Wis. Stats. (6) consent to sterilization. (7) consent to organ, tissue, or bone marrow donation. Report of Guardian ad Litem (Guardianship Due to Incompetency) Page 3 of 4 Case No. GN-3160, 02/16 Report of Guardian ad Litem (Guardianship Du e to Incompetency) §§54.40, 54.42 , 54.44 and 55.10, W isconsin Sta tutes This form shall not be modified. It may be supplemented with additional mater ial. Page 3 of 4 C. Powers to be transferred to Guardian of the Person in full or in part. I recommend the court transfer to the Guardian of the Person: See attached 1. A. The power to give an informed consent to the voluntary receipt by the ward of a medical examination, medication, including any appropriate psychotropic medication, and medical treatment that is in the ward's best interest, if the guardian has first made a good-faith attempt to discuss with the ward the voluntary receipt of the examination, medication, or treatment and if th e ward does not protest. Full Transfer. Partial Transfer. The individual retains the power to: 1. B. The power to give informed consent, if in the ward's best interests, to the involuntary administrat ion of a medical examination, medication other than psychotropic medication, and medical tre atment that is in the ward's best interest. Full Transfer. Partial Transfer. The individual retains the power to: 2. The power to authorize individual’s participation in an accredited or certified research p roject if the research project might help the individual, or others if minimal risk of harm. Full Transfer. Partial Transfer. The individual retains the power to: 3. The power to authorize individual’s participation in research that might not help the in dividual but might help others if greater than minimal risk of harm to the individual but evidence indicates individual would have elected to participate. Full Transfer. Partial Transfer. The individual retains the power to: 4. The power to consent to experimental treatment in the individual’s best interests. Full Transfer. Partial Transfer. The individual retains the power to: 5. The power to give informed consent to receipt by individual of social and supported living servi ces. Full Transfer. Partial Transfer. The individual retains the power to: 6. The power to give informed consent to release of confidential records other than court, treatment, and patient health care records and redisclosure as appropriate. Full Transfer. Partial Transfer. The individual retains the power to: 7. The power to make decisions related to mobility and travel. Full Transfer. Partial Transfer. The individual retains the power to: 8. The power to choose providers of medical, social, and supported living services. Full Transfer. Partial Transfer. The individual retains the power to: 9. The power to make decisions regarding educational and vocational placement and support services or employment. Full Transfer. Partial Transfer. The individual retains the power to: 10. The power to make decisions regarding initiating a petition for termination of marriage. Full Transfer. Partial Transfer. The individual retains the power to: 11. The power to receive all notices on behalf of individual. Full Transfer. Partial Transfer. The individual retains the power to: 12. The power to act in all proceedings as an advocate of the individual, except the power to enter into a contract that binds the individual or the individual’s property or to represent the indi vidual in any legal proceedings pertaining to the property, unless the guardian of the person is also the guardian of the estate. Full Transfer. Partial Transfer. The individual retains the power to: 13. The power to apply for protective placement or for commitment. Full Transfer. Partial Transfer. The individual retains the power to: 14. The power to have custody of the individual, if an adult, and the power to have care, custody, and control of the individual, if a minor. Full Transfer. Partial Transfer. The individual retains the power to: 15. Other: Report of Guardian ad Litem (Guardianship Due to Incompetency) Page 4 of 4 Case No. GN-3160, 02/16 Report of Guardian ad Litem (Guardianship Du e to Incompetency) §§54.40, 54.42 , 54.44 and 55.10, W isconsin Sta tutes This form shall not be modified. It may be supplemented with additional mater ial. Page 4 of 4 15. GUARDIAN OF THE ESTATE I recommend the court A. appoint a guardian of the estate to perform duties and exercise powers under §54.19, W is. Stats. and exercise powers that do not require court approval under §54.20(3), Wis. Stats., except as retained by the individual as follows : (Choose one) (1) The individual retains all rights, except for the following right(s), which will be transferred to the guardian: (2) All rights will be transferred to the guardian, except for the following right(s): . (3) All rights are transferred to guardian. B. authorize the guardian of the estate to perform the following additional powers (other than to make gifts) that require court approval under §54.20(2), Wis. Stats. : See attached C. direct the guardian of the estate deposit the individual’s funds of $100,000 or less in an insured account of a bank, credit union, savings bank or savings and loan association in the name of the guardian and the ward, payable only upon further order of the court, and waive bond for the guardian of the estate. 16. ALTERNATIVE TO GUARDIANSHIP OF ESTATE FOR SMALL ESTATES I recommend the court find that it is in the best interest of the individual to dispense wit h the appointment of a guardian of the e state and transfer the individual’s funds of $50,000 or less according to one of the alternatives for small estates under §54.12(1 ), Wis. Stats ., as follows: . See attached 17. GUARDIANSHIP, PROTECTIVE PLACEMENT, PROTECTIVE SERVICES It is my opinion the court should should not appoint a guardian of the person. should should not appoint a guardian of the estate with bond of $ . without bond. should should not approve protective placement. should should not approve protective services. should find the least restrictive placement consistent with the individual's needs and, if the individual has a developmental disability, the most integrated setting appropriate to the needs of the indivi dual, is a: group home. foster home. community based residential facility. nursing home . intermediate care facility. Other: in an unlocked unit. in a locked unit because: See attached 18. SUITABILITY AND FITNESS OF PROPOSED GUARDIAN My recommendation to the court regarding the fitness, suitability and the statement of acts of the proposed gua rdian, stand-by guardian, and any other person seeking to be appointed as guardian is: NAME SUITABILITY & FITNESS COMMENTS ON STATEMENT OF ACTS TYPE OF GUARDIAN Yes No person estate co -guardian standby Yes No person estate co -guardian standby Yes No person estate co -guardian standby 19. Additional comments: See attached DISTRIBUTION: 1. Court 2. Petitioner 3. Petitioner’s Attorney Guardian ad Litem Signature Name Printed or Typed Date State Bar Number