Fill and Sign the Wisconsin Guardianship Circuit Court Statewide Legal Form

GN-3170, 02/16 Determination and Order on Petition for Guardianship Due to Incompetency §54.10(3), 54.74, Chapter 46 and 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 1 of 6 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Determination and Order on Petition for Guardianship Due to Incompetency Date of Birth Case No. A petition for guardianship due to incompetency was filed and hearing held. After considerati on of the reports and other documents on file, all factors required by the statutes and such additional information presen ted THE COURT FINDS: 1. JURISDICTION, VENUE, NOTICE, APPEARANCES AND EVALUATIONS A. This court does does not have jurisdiction over the subject matter and over the person of the individual. B. This court is is not a proper venue. C. Notice was was not properly served. D. The individual is present. not present because the guardian ad litem waived the individual’s attendance. Other: E. The proposed guardian and any proposed stand-by guardian are present as follows: not present and the court permits attendance by telephone for good cause shown as follows: not present and the court excuses the attendance as follows: F. Additional evaluations are not necessary. 2. CAPACITY AND NEED FOR GUARDIANSHIP Upon presentation of clear and convincing evidence, the individual is not incompetent. advanced planning by the individual renders guardianship unnecessary. the elements of the petition are unproven. the application for appointment of a conservator by the proposed ward under §54.76, Wis. Stats., is appropriate. the individual was adjudicated incompetent in another jurisdiction and a petition for r eceipt and acceptance of a foreign guardianship was granted. the individual is a minor who has attained age 14 and is developmentally disabl ed. the individual is found to be incompetent as a result of: a developmental disability serious and persistent mental illness degenerative brain disorder other like incapacities based upon the following standards: A. The individual is at least 17 years and 9 months of age. B. The individual’s need for assistance in decision-making or communication is unable to be met effectively and less restrictively through appropriate and reasonably available training, educ ation, support services, health care, assistive devices, or other means that the individual will accept. C. (For appointment of guardian of the person ) The individual, because of impairment, is unable effectively to receive and evaluate information or to make or communicate decisions to suc h extent that the individual is unable to meet the essential requirements for the individual’s phys ical health and safety. Determination and Order on Petition for Guardianship Due to Incompetency Page 2 of 6 Case No. __________ GN-3170, 02/16 Determination and Order on Petition for Guardianship Due to Incompetency §54.10(3), 54.74, Chapter 46 and 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 2 of 6 D . (For appointment of guardian of the estate ) The individual, because of an impairment, is unable effectively to receive and evaluate information or to make or communicate decisions rela ted to management of the individual’s property or financial affairs, to the extent that at least one of the following applies: (1) The individual has property that will be dissipated in whole or in part; or (2) The individual is unable to provide for the individual’s support ; or (3) The individual is unable to prevent financial exploitation. 3. GUARDIAN OF THE PERSON The individual is in need of a guardian of the person. A. Rights to be removed in full. If removed, these rights may not be exercised by any person. The individual has incapacity to exercise the following rights: (1) execute a will. (2) serve on a jury. (3) register to vote or to vote in an election. B. Rights to be removed in full or exercised by individual only with consent of Guardian of Person. The individual has incapacity to exercise the following rights: Ward may not exercise this right. Remove right in full. Ward may exercise only with the consent of the Guardian of the Person. (1) consent to marriage. (2) apply for an operator’s/driver’s license. (3) apply for a fishing license. (4) apply for a license under Ch. 29, W is. Stats., other than fishing. (5) apply for a credential under §440.01(2), Wis. Stats. (6) consent to sterilization. (7) consent to organ, tissue, or bone marrow donation. C. Powers to be transferred to Guardian of the Person in part or in full. The court transfers to the Guardian of the Person: 1. A. The power to give an informed consent to the voluntary receipt by the ward of a medical examination, medication, including any appropriate psychotropic medication, and medical treatm ent th at is in the ward's best interest, if the guardian has first made a good-faith attempt to discuss with the ward the voluntary receipt of the examination, medication, or treatment and if the ward does not protest. Full Transfer. Partial Transfer. The individual retains the power to: 1. B. The power to give informed consent, if in the ward's best interests, to the involuntary administrat ion of a medical examination, medication other than psychotropic medication, and medical tre atment that is in the ward's best interest. Full Transfer. Partial Transfer. The individual retains the power to: 2. The power to authorize individual’s participation in an accredited or certified research p roject if the research project might help the individual, or others if minimal risk of harm. Full Transfer. Partial Transfer. The individual retains the power to: 3. The power to authorize individual’s participation in research that might not help the in dividual but might help others if greater than minimal risk of harm to the individual but evidence indicates individual would have elected to participate. Full Transfer. Partial Transfer. The individual retains the power to: 4. The power to consent to experimental treatment in the individual’s best interests. Full Transfer. Partial Transfer. The individual retains the power to: 5. The power to give informed consent to receipt by individual of social and supported living servi ces. Full Transfer. Partial Transfer. The individual retains the power to: 6. The power to give informed consent to release of confidential records other than court, treatment, and patient health care records and redisclosure as appropriate. Full Transfer. Partial Transfer. The individual retains the power to: 7. The power to make decisions related to mobility and travel. Full Transfer. Partial Transfer. The individual retains the power to: Determination and Order on Petition for Guardianship Due to Incompetency Page 3 of 6 Case No. __________ GN-3170, 02/16 Determination and Order on Petition for Guardianship Due to Incompetency §54.10(3), 54.74, Chapter 46 and 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 3 of 6 8. The power to choose providers of medical, social, and supported living services. Full Transfer. Partial Transfer. The individual retains the power to: 9. The power to make decisions regarding educational and vocational placement and support servic es or employment. Full Transfer. Partial Transfer. The individual retains the power to: 10. The power to make decisions regarding initiating a petition for termination of marriage. Full Transfer. Partial Transfer. The individual retains the power to: 11. The power to receive all notices on behalf of individual. Full Transfer. Partial Transfer. The individual retains the power to: 12. The power to act in all proceedings as an advocate of the individual, except the power to enter into a contract that binds the individual or the individual’s property or to represent the individ ual in any legal proceedings pertaining to the property, unless the guardian of the person is also the guardian of the estate. Full Transfer. Partial Transfer. The individual retains the power to: 13. The power to apply for protective placement or for commitment. Full Transfer. Partial Transfer. The individual retains the power to: 14. The power to have custody of the individual. Full Transfer. Partial Transfer. The individual retains the power to: 15. Other: See attached 4. GUARDIAN OF THE ESTATE It is appropriate to A. appoint and authorize a permanent guardian of the estate to perform duties and exercise powers under §54.19, Wis. Stats., and exercise the powers that do not require court approval under §54.20(3), W is. Stat s., except as retained by individual as follows: (Choose one) (1) The individual retains all rights, except for the following right(s) which will be transferred to the guardian: (2) All rights will be transferred to the guardian, except for the following right(s): (3) All rights are transferred to guardian. B. authorize the guardian of the estate to perform the following additional powers (other than to make gifts) that require court approval under §54.20(2), Wis. Stats. : See attached C. direct the guardian of the estate deposit the individual’s funds of $100,000 or less in an insured account of a bank, credit union, savings bank or savings and loan association in the name of the guardian and t he ward, payable only upon further order of the court, and waive bond for the guardian of the estate. 5. ALTERNATIVE TO GUARDIANSHIP OF ESTATE FOR SMALL ESTATES Even though the individual meets the standards for appointment of a guardian of the estate , it is appropriate to dispense with the appointment of a guardian of the estate and transfer the individual’s funds of $50,000 or less according to one of the alternatives for small estates under §54.12(1), Wis. Stats., as follo ws: See attached 6. POWERS OF ATTORNEY Even though the ward has executed a financial durable power of attorney, has a current, valid power of attorney for health care, or other advanced planning, guardianship is still necessary, for the following reasons: See attached Good cause exists to revoke or limit the power of attorney for health care because: See attached Good cause exists to revoke or limit the durable financial power of attorney because: See attached Determination and Order on Petition for Guardianship Due to Incompetency Page 4 of 6 Case No. __________ GN-3170, 02/16 Determination and Order on Petition for Guardianship Due to Incompetency §54.10(3), 54.74, Chapter 46 and 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 4 of 6 The appointment of the agent under the individual’s power of attorney for health care as guardian of t he person is not in the best interest of the individual because: See attached The appointment of the agent under the individual’s durable financial power of attorney as guardian of the estate is not in the best interest of the individual because: See attached 7. SUITABILITY OF GUARDIAN Based upon the Statement of Acts by Proposed Guardian and Consent to Serve , the recommendation of guardian ad litem, and the court having considered all nominations and applicable preferences and cr iteria, including the opinions of the proposed ward and of the members of his or her family, and any potential confli cts of interest resulting from the proposed guardian's employment or other potential conflicts of interest, the follo wing person or organization is competent and suitable to be appointed: Type of Guardian Name and Address Phone Guardian of the Person Guardian of the Estate Standby Guardian of the Person Standby Guardian of the Estate 8. PETIT IONER’S ATTORNEY FEES AND COSTS It is equitable inequitable to award payment of petitioner’s reasonable attorney fees and costs from the i ndividual’s income and assets. 9. Other: THE COURT ORDERS: The petition is dismissed. granted as follows: 1. POWERS OF ATTORNEY A. The power of attorney for health care remains in effect. is revoked. is limited as follows: . See attached B. The durable financial power of attorney: remains in effect. is revoked. is limited as follows: . See attached 2. APPOINTMENT OF GUARDIAN A. The court appoints the person(s) nominated as guardian to serve in the capacities indicated. B. The guardian is authorized to exercise powers in part or in full consistent with the above fin dings in a manner that is appropriate to the individual and that constitutes the least restrictive form of i ntervention. C. Co-guardians must agree with each other when making decisions on behalf of the individual subject to guardianship. Co-guardians may act independently when making decisions on behalf of the individu al. Co-guardians may act independently when making decisions on behalf of the individual only in these limited circumstances: . D. Any guardian shall immediately notify the court in writing of any change in the address of the individual or of any guardian. Determination and Order on Petition for Guardianship Due to Incompetency Page 5 of 6 Case No. __________ GN-3170, 02/16 Determination and Order on Petition for Guardianship Due to Incompetency §54.10(3), 54.74, Chapter 46 and 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 5 of 6 3. APPOINTMENT OF GUARDIAN OF PERSON A. FIREARM RESTRICTION The individual is prohibited from possessing any firearm. Federal law provides penal ties for, and you may be prohibited from possessing, transporting, shipping, receiving, or pu rchasing a firearm, including, but not limited to, a rifle, shotgun, pistol, revolver, or ammunition, pursuant to 18 U.S.C. 921(a)(3) and (4) and 922(g)(4). This prohibition shall remain in effect until lifted by the court. (1) Any firearm owned by subject shall be seized by . Individual’s firearms may be found at the following location(s): . Any person residing at the/these locations is required to cooperate with law enforcemen t attempts to seize firearms. Failure to cooperate may result in contempt sanctions. (2) As an alternative to seizure, the following person is designated to store any firearm( s) until the firearm restriction order has been canceled: . (3) Individual is informed of the requirements and penalties under §941.29, W is. Stats., including imprisonment for up to 10 years, a fine not to exceed $25,000 or both. (4) The court clerk shall notify the department of justice of the restriction unless the de partment was previously informed of a prohibition for this individual. B. The guardian of person shall file Annual Report on the Condition of the Ward. 4. APPOINTMENT OF GUARDIAN OF ESTATE A. BOND The guardian of the estate will be issued letters of guardianship upon filing surety bond signature bond in the amount of $ . is not required to file a bond provided that the guardian shall deposit the individual ’s funds of $100,000 or less in an insured account in the name of the guardian and the individual, and payable only upon further order of the court. Proof of deposit shall be filed with the court wit hin days. will be issued letters of guardianship without filing a bond. Other: See attached B. INVENTORY AND ANNUAL ACCOUNT (1) The guardian of the estate shall file an inventory of the individual’s assets within 60 days and provide a copy of the inventory to the following persons: (2) The guardian of the estate shall file an annual account by April 15 of each y ear or as otherwise required by the court as follows: 5. ALTERNATIVE TO GUARDIANSHIP OF ESTATE As an alternative to appointing a guardian of the estate, the individual’s funds of $50,000 or l ess shall be transferred according to one of the alternatives for small estates under §54.12(1), Wis. Stats., as f ollows: 6. FEES AND COSTS OF PROCEEDING A. Guardian is not appoint ed. The petitioner shall pay the compensation of the guardian ad litem and the individual’s legal counsel. B . Gu ardian is appointed. (1) Reasonable compensation of the guardian ad litem and individual’s counsel shall be paid f rom the individual’s income or assets, if sufficient. If the individual’s income or assets are i nsufficient, the guardian ad litem shall be paid by the county of venue and the individual’s coun sel shall be paid at public expense or by the county of venue. (2) Petitioner’s reasonable attorney fees and costs shall be paid by the petitioner. from the individual’s income or assets. C . Other: Determination and Order on Petition for Guardianship Due to Incompetency Page 6 of 6 Case No. __________ GN-3170, 02/16 Determination and Order on Petition for Guardianship Due to Incompetency §54.10(3), 54.74, Chapter 46 and 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 6 of 6 7. GUARDIAN’S COMPENSATION AND REIMBURSEMENT The guardian’s compensation and reimbursement of expenses, if any, must be approved by the court before payment is made . 8. Other: THIS IS A FINAL ORDER FOR PURPOSES OF APPEAL IF SIGNED BY A CIRCUIT COURT JUDGE. BY THE COURT: Name of Attorney Circuit Court Judge/Circuit Court Commissioner Print or Type Name if not eSigned Date Address Telephone Number Bar Number