Fill and Sign the Wisconsin Protective Placement 497431049 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Petition for Annual Review of Protective Placement       Date of Birth Case No.       UNDER OATH, I STATE THAT: 1. I am a representative of the county department of the individual’s county of residence. 2. This individual is currently placed in: Name of facility:       Address of facility:       Contact person at facility:       Phone number of contact person:       3. The county department’s annual report of the review of the status of this individual is filed or will be filed. A copy of this report has been provided to the individual, guardian of the individual and the individual’s agent under any activated power of attorney for health care. 4 . This individual has developmental disabilities and is currently protectively placed in an intermediate facility or nursing facility. The plan for providing home or community-based care in a noninstitutional community setting, intermediate facility or nursing facility which would be the most integrated setting appropriate to the needs of this individual is filed or will be filed. A copy of this plan shall be sent to the individual’s guardian. 5. Therefore, I request that the court review the status of the protective placement of this individual. Subscribed and sworn to before me on       Notary Public/Court Official My commission expires:       Signature of Petitioner       Name Printed or Typed       Address       GN-4080, 10/06 Petition for Annual Review of Protective Placement §§46.279, and 55.18(1),(a),(2), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.