Fill and Sign the Certification on Request to Form

GN-3830, 04/07 Certification on Request to Transfer Guardianship to W isconsin §54.38(1m)(a) 2., W isconsin Statutes This form shall not be modified. It may be supplemented with additional mat erial. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Certification on Request to Transfer Guardianship to Wisconsin Date of Birth Case No. To Circuit Court of: County, Wisconsin This Certification is made by Court, State of regarding Guardianship for this individual under the jurisdiction of this court as case number . 1. Notice has been received by this court that a petition has been filed in Circuit Court i n County, State of W isconsin requesting transfer of this guardianship from the State of to the State of Wisconsin. 2. This court has been requested to provide this Certification and copies of all d ocuments filed that are relevant to this guardianship. 3. Except as noted below, this court has no knowledge that the guardian has engaged in any ac ts specified in § 54.68(2)(a) to (i), Wis. Stats., as follows: a. failing to file timely an inventory or account, as required, that is accurate and complete. b. committing fraud, waste or mismanagement. c. abusing or neglecting the ward or knowingly permitting others to do so. d. engaging in self-dealing. e. failing to provide adequately for the personal needs of the ward from t he ward’s available assets and income, including any available public funds. f. f ailing to exercise due diligence and reasonable care in assuring that the ward’s p ersonal needs are being met in the least restrictive environment consistent with the ward’s needs and incapacities. g. failing to act in the best interests of the ward. h. failing to disclose conviction for a crime that would have prevented appointment of the pe rson as guardian. i. failing to disclose that the guardian is listed in the caregiver misconduct registr y under §146.40(4g)(a)2., Wisconsin Statutes. 4 . Except as noted below, this court has no knowledge that the guardian has failed to perform any duties of a guardian required by this jurisdiction or this court. 5 . Except as noted below, this court has no knowledge that the guardian has performed any acts prohib ited to a guardian by this jurisdiction or this court. 6. Exceptions: See attached Name of Attorney Court Official Print or Type Name if not eSigned Date Address Telephone Number Bar Number