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GN-4 08 0, 1 0/0 6 P etit io n f o r A nn ual R evie w o f P ro te ctiv e P la ce m ent §§4 6.2 79 , a nd 5 5.1 8 (1 ),( a ),( 2 ), W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l. S TA TE O F W IS C O NSIN , C IR CUIT C O URT, C O UNTY IN T H E M ATTE R O F A m en ded P etit io n f o r A nnual R evie w o f P ro te ctiv e P la cem en t D ate o f B ir th C ase N o. For O ff ic ia l U se U NDER O ATH , I S TA TE T H AT: 1. I a m a r e pre se nta tiv e o f th e c o unty d epartm ent o f th e in div id ua l’s c o unty o f r e sid ence . 2. T his in div id u al is c u rre ntly p la ce d in : Nam e o f f a cilit y : Addre ss o f f a cilit y : Conta ct p ers o n a t f a cil it y : Pho ne n um ber o f c o nta ct p ers o n: 3. The c o unty d e partm ent’s a nnua l r e port o f th e r e vie w o f th e s ta tu s o f th is in div id ua l is f il e d o r w ill b e f il e d. A c o p y o f th is r e port h as b ee n p ro vid ed t o t h e in d iv id ual, g uard ia n o f th e in div id ua l a nd th e in d iv id u al’s a g ent u nder a n y a ctiv a te d p o w er o f a tto rn e y f o r h ea lt h c a re . 4 . This in div id u al h as d e ve lo pm enta l d is a bilit ie s a nd is c u rre ntly p ro te ctiv e ly p la ce d in a n in te rm edia te f a cil it y o r n urs in g f a cilit y . T he p la n f o r p ro vid in g h om e o r c o m mun it y -b ase d c a re in a n o nin stit u tio n al c o m m unit y s e ttin g, in te rm edia te f a cilit y o r n urs in g f a cil it y w hic h w ould b e t h e m ost in te gra te d s e ttin g a p pro pria te to t h e n eeds o f th is in div id u al is f il e d o r w il l b e f ile d. A c o p y o f th is p la n s h a ll b e s e nt to t h e in d iv id u al’s g u ard ia n. 5. T here fo re , I r e q uest th at th e c o urt r e vie w th e s ta tu s o f th e p ro te ctiv e p la ce m ent o f th is in div id u al. Sig natu re o f P etit io n er N am e P rin te d o r T yp ed Addre ss S ubsc rib ed a nd s w orn to b efo re m e o n N ota ry P ublic /C ou rt O ffic ia l M y c o m m is s io n e xp ir e s: