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Fill and Sign the Court Paymentsmonona Wi Official Website City of Monona Form

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CR-254, 08/11 Petition to Modify Bifurcated Sentence §302.113(9g) §302.113(9g), W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. 1. I was sentenced for the crime of , on [Date] . · The total length of my bifurcated sentence on this count is years, months. · My initial term of confinement in prison is years, months. · My initial term of extended supervision is years, months. I was sentenced for the crime of , on [Date] . · The total length of my bifurcated sentence on this count is years, months. · My initial term of confinement in prison is years, months. · My initial term of extended supervision is years, months. I was sentenced for the crime of , on [Date] . · The total length of my bifurcated sentence on this count is years, months. · My initial term of confinement in prison is years, months. · My initial term of extended supervision is years, months. 2. I am not serving a sentence for a Class A or B felony. 3. A. I have not previously filed a petition for modification of bifurcated sentence. OR B. I have previously had a petition for modification of bifurcated sentence denied by the P rogram Review Committee. The denial was on [Date] , and it has been over one year since that denial. OR C. I have previously had a petition for modification of bifurcated sentence denied by the court. The denial was on [Date] , and it has been over one year since that denial. 4. A. I am 65 years of age or older and have served at least 5 years of the term of confinement in pr ison. OR B. I am 60 years of age or older and have served at least 10 years of the term of confinement in p rison. OR C. I have an extraordinary health condition, and have attached affidavits from two (2) physicians setting forth a diagnosis that I have an extraordinary health condition. 5. My attorney ’s name (If any) : Address: Telephone: Fax: 6. I request appointment of an attorney. 7. I request sentence modification. DISTRIBUTION: 1. Pro gram Review Committee ► Petitioner Name Typed or Printed Date STATE OF WISCONSIN, CIRCUIT COURT, COUNTY State of W isconsin -vs - , Defendant Name Date of Birth Amended Petition to Modify Bifurcated Sentence §302.113(9g), Wis. Stats. (Geriatric/Extraordinary Health Condition) Case No.

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