Fill and Sign the Statement of Acts by Form

GN-3140, 01/09 Statement of Acts by Proposed Guardian and Consen t to Serve as Guardian §223.105(2), 54.15(8), 54.15(9), 54.60, and 54.62 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 Acts by Proposed Guardian and Consent to Serve As Guardian 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, W isconsin Statutes or by the laws of another state for the practice of a profession or occupation has been suspended or rev oked. 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), Wis. Stat s. 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 estat e of the above named individual and consent to serve as guardian and will act in the best interes t of this individual. 7. If appointed as guardian of the person , I will file the Annual Report on the Condition of the W ard. 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. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Proposed Guardian Name Printed or Typed Address Phone Number Name of Attorney Address Telephone Number Bar Number