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GN -4040 , 11/12 Petition for Protective Placement/Protective Services §46.279, Chapter 54 and 55 , W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Petition for Protective Placement Protective Services Date of Birth Case No. UNDER OATH, I STATE : 1. I am interested as Wisconsin D epartment of Health Services . the county department or an agency with which the county department cont racts . a guardian . an interested person [Indicate relationship to individual ] . Other: [Indicate relationship to individual ] 2. This petition is filed in the county in which the individual resides . is physically present due to extraordinary circumstances . Other: 3. The individual resides in County, State of , and the individual’s mailing address is [Street, City, State, Zip ] . 4. The names and mailing addresses of all interested par ties (including the petitioner) and all others entitled to notice are as follows: See attached NAME RELATIONSHIP MAILING ADDRESS (Street, City, State and Zip) 5. The individual, if married , does does not have children who are not of the current marriage. 6. The individual does does not have a current, valid financial durable power of attorney activated. Name, address and phone: does does not have a curren t, valid power of attorney for health care activated. Name, address and phone: does does not have other advance planning to avoid protective placement . If the above -named powers of attorney or advanced planning exist, protective placement is still necessary because: . See attached Petition for Protective Placement/Protective Services Page 2 of 3 Case No. GN -4040 , 11/12 Petition for Protective Placement/Protective Services §46.279, Chapters 54 and 55 , W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 7. A. A petition for permanent guardianship is filed with this petition . B. A guardian was appointed in this county. another county in this state [Name of guardian and county where appointed ] another state [Name of guardian and state where appointed ] 8. The name and mailing address of the person or institution, if any, that has care and custody of the individual or the facility, if any, that is providing care to the individual is: Name Phone N umber Mailing Address Type of facility: community based residential f acility Is this facility licensed for 16 or more beds? Yes No intermediate f acility center for developmentally d isabled nursing f acility Other: 9. I am requesting protective placement and/or protective services for the individual, based upon personal knowledge of the individual, and I state A. The individual is eligible for protective p lacement because the individual has attained the age of 18. is alleged to have a d evelopment al disability and has attained the age of 14. B. A petition for adult protective placement is initiated not more than 6 months prior to the individual’s birthday at which the individual first becomes eligible for placement. C. The individual was adjudicated incompetent in Wisconsin more than 12 months before the filing of this petition for protective placement and/or protective services and a court review is r equired of the finding of incompetency. D. The non -resident individual has a need for protective placement and/or protective services and a separate petition to transfer a for eign guardianship was filed whether the individua l is present in the state . E. A comprehensive evaluation and community plan (if required ) and recommendation for placement by the appropriate board or designated agency is filed . will be filed. A copy of the comprehensive evaluation and any independent comprehensive evaluatio n will be provided to the individual’s guardian, agent under any activated health care power of attorney, guardian ad litem, the individual and the individual’s attorney at least 96 hours in advance of the hearing to determine protective placement or prote ctive services. FOR PROTECTIVE PLACE MENT 10. A. The individual needs protective placement and meets the standards for prot ective placement specified in §55 .08 (1), Wis. Stat s., as follows: 1) The individual has a primary need for residential care and custody. 2) Except in the case of a minor that is age 14 or older, who is alleged to have a developmental disab ility, the individual has either been adjudicated to be incompetent by a circuit court or a petition for guardianship was submitted on the minor’s behalf; 3) As a result of a developmental disability degenerative brain disorder seriou s and persistent mental illness other like incapacities, the individual is so totally incapable of providing for his or her own care or custody as to create a substantial risk of serious harm to himself or herself or others. Serious harm may be evidenced by overt acts or acts of omission. 4) The individual has a disability that is permanent or likely to be permanent. B. The specific facts and details of how the individual meets the standards for protective placement and needs protective placement are as follows: See attached C. The individual is alleged to have a development al disability . D. The petitioner requests protective placement of the individual in the following facility: or a like facility. Petition for Protective Placement/Protective Services Page 3 of 3 Case No. GN -4040 , 11/12 Petition for Protective Placement/Protective Services §46.279, Chapters 54 and 55 , W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 E. A locked unit is necessary because: F. This petition for protective placement is filed prior to transfer of the individual directly from a hospital to a nursing home or community -based residential facility and the individual does does not verbally object to or otherwise actively protest the admission. FOR PROTECTIVE SERVICES 11. A. The individual meets all of the standards as follows for pro tective services specified in § 55.08 (2), W is. Stat s. 1) The individual was determined incompetent by a circuit court or is a minor who is alleged to have a development al disability and on whose behalf a petition for guardianship was submitted, and 2) As a result of a developmental disability , degenerative brain disorder, serious and persistent mental illness, or other like incapacities, the individual will incur a substantial risk of physical harm or deterioration or will present a substantial risk of physical harm to others if protective services are not provided. B. The specific facts and details explaining how the individual meets the stan dards for protective services and needs protective services are as follows: See a ttached I REQUEST THE COURT: 1. Order a hearing on this petition. 2. Make appropriate findings and order protective placement of the individual. protective services for the individual. 3. Award appropriate f ees and costs. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires:  Petitioner Name Printed or Typed Address Date Name of Attorney /Petitioner Address Telephone Number Bar Number