Fill and Sign the Petition Protection of Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use In the interest of J. Doe, an unborn child, and       the unborn child's expectant mother. Petition for Protection or Care of an Unborn Child (Chapter 48)       Date of Birth Case No.       I state on information and belief that the following is true (if unknown or cannot be ascertained, so state): 1. The estimated gestational age of the unborn child is       weeks. Expectant Mother's Street and City Address       If expectant mother is a child (17 or under): Father's Name and Address       Father’s Birthdate       Mother's Name and Address       Mother’s Birthdate       Name and Address of Guardian, Legal Custodian, Spouse, if any       If expectant mother is an adult (18 or over): Spouse's name and address, or if no spouse, nearest relative's name and address       Expectant mother in temporary physical custody? No Yes: Date/Time:       Where held:       Not disclosed - threat of imminent danger to unborn child/expectant mother/physical custodian. Unborn child is subject to federal Indian child welfare act? (25 USC §§1911-1963) No Unascertainable Yes: Tribe/address:       2. The unborn child is in need of protection or care. 3. The expectant mother is in need of supervision, services, care or rehabilitation. 4. The reliable and credible information which forms the basis for the allegations, including the conduct or circumstances to be considered by the court is: See attached.       I request adjudication and entry of an appropriate dispositional order. Distribution: 1. Original - Court 2. Expectant mother 3. Parents of expectant mother (if a child) 4. Guardian/Legal custodian/Physical custodian/ GAL of expectant mother 5. GAL of unborn child 6. Indian tribe (if applicable and known) Signature: District Attorney/Corporation Counsel Counsel /GAL of Expectant Mother GAL of Unborn Child       Name Printed or Typed       Date JC-1612 , 10/06 Petition for Protection or Care of an Unborn Child (Chapter 48) §§48.133 and 48.255(1m), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.