Fill and Sign the Petition for Examination Wisconsin Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF THE CONDITION OF       Name of Subject Petition for Examination       Date of Birth Case No.       Under oath, we petition the court to examine the condition of the subject, who resides in       , County at       , and allege that: Address a. The subject is mentally ill, drug dependent, or developmentally disabled and a proper subject for treatment because:       See attached. b. The subject is dangerous to himself/herself or others because:       See attached. c. The following petitioner(s) has pers onal knowledge of the conduct of the subject: Name Address Telephone Relationship to Subject 1)                         2)                         3)                         d. The following petitioner(s) does not have personal knowledge of the conduct of the subject but bases his/her belief on the following: Name Address Telephone Relationship to Subject 1)                         Basis for Belief:       ME-903 , 12/02 Petition for Examination §51.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Petition for Examination Page 2 of 3 Case No. 2)                         Basis for Belief:       e. In addition to the petitioners, the following person(s) may testify in support of this petition: Name Address Telephone                                                                         f. The names and post office address of subject's: (If unknown or inapplicable, so state.) Spouse Post Office Address             Adult Children Post Office Address                                     Parents or Guardian Post Office Address             Custodian Post Office Address             Brothers/Sisters Post Office Address                                     Person(s) With Whom Subject Resides Post Office Address                         ME-903 , 12/02 Petition for Examination §51.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 Petition for Examination Page 3 of 3 Case No. Signature of Petitioner Name Printed or Typed Subscribed and sworn to before me on       Notary Public/Court Official, State of Wisconsin My commission expires                         ME-903 , 12/02 Petition for Examination §51.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3