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Fill and Sign the State of Wisconsin Circuit Court County for Official Use Form

Fill and Sign the State of Wisconsin Circuit Court County for Official Use Form

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GN-4010, 05/17 Notice of Rights for 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 Notice of Rights of Emergency Protective Placement Date of Birth Case No. I am the director director’s designee of the facility in which the individual is detained. You have been detained for emergency protective placement. You are notified that you have the following rights:  To contact an attorney.  To have an attorney provided at public expense.  To contact a member of your immediate family. You will be notified of the time and place of the hearing to establish probable cause for protectiv e placement. This hearing must be held within 72 hours of your detention, excluding Saturdays, Sundays and legal holidays. A copy of the Statement of Emergency Protective Placement is being provided to you wi th this Notice of Rights along with a copy of the petition for protective placement (individual currently under guardianship). guardianship and petition for protective placement. protective placement (minor alleged to be developmentally disabled). I am providing you with this Notice of Rights both orally and in writing on [Date] at [Time] a.m. p.m. Signature of Director of Facility or Designee Name of Facility and Address Name Printed or Typed Telephone Number DISTRIBUTION: 1. Court 2. Individual 3. Facility

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