Fill and Sign the State of Wisconsin Circuit Court County Family Branch Case No Form

GN-4000, 01/09 Statement of Emergency Protective Placement §55.135, W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Statement of Emergency Protective Placement Date of Birth Case No. 1. I am a sheriff or police officer. a fire fighter. a guardian. an authorized representative of the county department or an agency with which it contracts under §55.02(2), Wis. Stats. 2. It appears probable that the individual is so totally incapable of providing for the individual’s own care or custody as to create a substantial risk of serious physical harm to the individual or others as a r esult of a developmental disability, degenerative brain disorder, serious and persistent mental illness or other like inca pacities if not immediately placed in an appropriate medical or protective placement facility. The specific factual information that is the basis for the emergency protective placement, based on p ersonal observation or a reliable report by a person identified to me, is as follows: See attached 3. A petition for protective placement is being filed with this statement. A petition for guard ianship is also being filed unless: A. Th e individual is currently under guardianship; OR B. The individual is a minor who is alleged to have a developmental disability. 4. The individual was detained at , [Name of Facility] , on [Date] , at [Time] a.m. p.m. Subject’s Street A ddress City County State Zip code Signature of Person Making Placement Name of Department and Address Name Printed or Typed Telephone Number DISTRIBUTION: 1. Court 2. Individual 3. Facility 4. Guardian ad Litem 5. Department 6. Other: