Fill and Sign the Wisconsin Protective Placement 497431055 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Petition Objecting to Transfer of Protective Placement       Date of Birth Case No.       1. I am the: individual under protective placement. individual’s guardian. individual’s attorney. other interested person:       2. I object to the transfer because: the transfer is to a unit for the acutely mentally ill. the transfer is to a locked unit without a specific finding from the court as to the need. the individual has developmental disabilities and the transfer is to an intermediate facility or nursing facility without development of a community plan or a community plan being furnished to the county department or agency and to the individual’s guardian. the transfer is not to the least restrictive environment or in the least restrictive manner consistent with the needs of the individual under protective placement or the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds. the transfer is to an intermediate facility or nursing facility that is not in the most integrated setting that enables an individual to interact with persons without developmental disabilities to the fullest extend possible. the protective placement is not in the best interest of the individual under protective placement. Other:       See attached. 3. I request the court appoint a guardian ad litem and conduct a hearing within 10 days after the filing of this petition to determine whether to approve the proposed transfer or emergency transfer. Subscribed and sworn to before me on       Notary Public, State of Wisconsin My commission expires:       _____________________________________________ Signature of Petitioner       Name Printed or Typed       Address Name of Attorney       Address       Telephone Number       Bar Number       Original: Court Copies: Petitioner Guardian County department or agency with which it contracts. Individual under protective placement Protective placement facility GN-4350, 10/06 Petition Objecting to Transfer of Protective Placement §55.15(6), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Individual’s attorney, if any PR-0000 , 05/00 Title Line 1 Title Line 2 Title Line 3 §§ ,Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2