Fill and Sign the Gn 4350 Form

GN-4 35 0, 1 0/0 6 P etit io n O bje ctin g to T ra nsfe r o f P ro te ctiv e P la ce m ent §55 .1 5 (6 ), 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 O bje ctin g t o T ra n sfe r 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 1. I a m th e: in d iv id ual u n der p ro te ctiv e p la ce m ent. in d iv id ual’s g uard ia n. in d iv id ual’s a tt o rn e y. oth er in te re ste d p ers o n: 2 . I o bje ct to th e tr a nsfe r b eca use : th e tr a nsfe r is to a u nit f o r th e a cu te ly m enta lly ill. th e tr a nsfe r is to a lo ck e d u nit w it h out a s p ecif ic f in d in g f r o m th e c o urt a s to t h e n e ed. th e in d iv id ual h as d e ve lo p m enta l d is a bilit ie s a nd t h e t r a nsfe r is to a n in te rm edia te f a cilit y o r n urs in g f a cilit y w it h o ut d eve lo pm ent o f a c o m m unit y p la n o r a c o m m unit y p la n b ein g f u rn is h ed t o th e c o u nty d epartm ent o r a gency a nd t o th e in div id ua l’s g uard ia n. th e tr a nsfe r is n ot t o th e le a st r e str ic tiv e e n vir o nm ent o r in th e le ast r e str ic tiv e m anner c o nsis te nt w it h t h e n eeds o f th e in d iv id ual u nder p ro te ctiv e p la ce m ent o r th e r e so urc e s o f th e c o unty d ep artm ent, i n clu din g t h e lim it s o f a va ila ble s ta te a nd f e d era l f u n ds, a nd c o unty f u nds r e quir e d to b e a p pro pria te d t o m atc h s ta te f u nds. th e tr a nsfe r is to a n in te rm ed ia te f a cil it y o r n urs in g f a cili t y th at is n ot in th e m ost in te gra te d s e tt in g th at e na ble s a n in d iv id ua l t o in te ra ct w it h p ers o ns w it h out d eve lo pm enta l d is a b ilit ie s to th e f u ll e st e xte nd p ossib le . th e p ro te ctiv e p la ce m ent is n ot in t h e b est in te re st o f th e in div id ua l u nd er p ro te ctiv e p la ce m ent. Oth er: S ee a tta ch ed . 3 . I r e quest th e c o urt a ppo in t a g u ard ia n a d lit e m a nd c o nduct a h e arin g w it h in 1 0 d ays a fte r t h e f il in g o f th is p etit io n to d ete rm in e w heth er to a ppro ve t h e p ro pose d tr a nsfe r o r e m erg ency tr a n sfe r. S ubscrib ed a nd s w orn to b efo re m e o n N ota ry P ublic , S ta te o f W is co nsin M y c o m m is s io n e xp ir e s: _ _________________________________ __________ Sig natu re o f P etit io n er Nam e P rin te d o r T yp ed Addre ss N am e o f A tto rn ey Addre ss Tele ph on e N um ber B ar N um ber Orig in al: C ourt C opie s: P etit io ner G uard ia n C ounty d epartm ent o r a gency w it h w hic h it c o ntr a cts . I n div id ual u nder p ro te ctiv e p la ce m ent P ro te ctiv e p la ce m ent fa cili t y I n div id ual’s a tt o rn ey, if a ny