Fill and Sign the Proposed Guardian Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Statement of Acts by Proposed Guardian and Statement of Acts by       Date of Birth Case No.       Submit this statement to the court at least 96 hours before the court hearing. UNDER OATH, I STATE THAT THE FOLLOWING IS TRUE: 1. I am currently charged with or have been convicted of a crime (misdemeanor or felony): No Yes If Yes, describe circumstances:       2. I have filed for or received protection under the federal bankruptcy laws: No Yes If Yes, describe circumstances:       3. Any license, certificate, permit, or registration that I am required to have under chs. 440 to 480, Wisconsin Statutes or by the laws of another state for the practice of a profession or occupation has been suspended or revoked: No Yes If Yes, describe circumstances:       4. I am listed in the Caregiver Misconduct Registry of the Department of Health Services under §146.40 (4g)(a)(2), Wisconsin Statutes. No Yes If Yes, describe circumstances:       5. I am currently a guardian of the person of 5 or more adult wards who are unrelated to me: No Yes If Yes, describe circumstances:       6. I am nominated to serve as: guardian standby guardian successor guardian of the person estate of the above named individual and consent to serve as guardian and will act in the best interest of this individual. 7. If appointed as guardian of the person , I will file the Annual Report on the Condition of the Ward. 8 . If appointed as guardian of estate , I will file the Guardianship Inventory within 60 days of appointment , and the Account of Guardian or Conservator annually and/or as otherwise required. 9. I will exercise all powers and perform all duties as guardian as required by law. Subscribed and sworn to before me on       Notary Public, State of Wisconsin My commission expires:       Signature of Proposed Guardian       Name Printed or Typed       Address       Phone NumberName of Attorney       Address       Telephone Number       Bar Number       GN-3140, 01/09 Statement of Acts by Proposed Guardian and Consent to Serve as Guardian §223.105(2), 54.15(8), 54.15(9), 54.60, and 54.62 Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.