Fill and Sign the Wisconsin Temporary Guardianship Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF             Amended Petition for Temporary Guardianship Permanent Guardianship Due to Incompetency       Date of Birth Case No.       FOR TEMPORARY AND/OR PERMANENT GUARDIANSHIPS (Complete #1 through #12) UNDER OATH, I STATE THAT: 1. I am interested as: a relative       . a public official. My authority to act as petitioner is:       . Other:       . 2. This petition is filed in: the county of residence of the individual. the county in which the individual is physically present. Other:       3. The residence of the individual is in       County, State of       , and individual’s post-office address is:       . 4. The name and post-office address of the person or institution, if any, that has care and custody of the individual or the facility, if any, that is providing care to the individual is: Name:       Phone Number:       Post-office Address:       This petition for guardianship is being filed prior to transfer of the individual directly from a hospital to a nursing facility or community-based residential facility. 5. I have exercised due diligence to locate all interested parties. The names and post office addresses of all interested parties (including the petitioner) and all others entitled to notice are as follows: See attached . NAME RELATIONSHIP POST-OFFICE ADDRESS                   6. The individual, if married, does does not have children who are not of the current marriage. 7. The individual: does does not have a current, valid financial durable power of attorney activated. Name, address and phone:       does does not have a current, valid power of attorney for health care activated. Name, address and phone:       does does not have other advance planning to avoid guardianship. If the above-named powers of attorney or advanced planning exist, guardianship is still necessary because:       . GN-3100, 01/07 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency §§50.06, 54.10(3), 54.34, 54.50, 54.852(7) and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 5 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency Page 2 of 6 Case No. See attached . 8. I am not aware aware of a guardianship or conservatorship or related proceeding or ordered proceeding involving the individual in another state or county. The details of the guardianship, conservatorship, or related proceedings of which I am aware are as follows: See attached. guardian or conservator appointed in Wisconsin: (Name and county where appointed)       guardian or conservator appointed out-of-state: (Name and state where appointed )       A separate petition for receipt and acceptance of a foreign guardianship is being filed. 9. A report of examination by a physician or psychologist: is being filed at this time. will be filed at least 96 hours before the hearing. will be provided by testimony or report at hearing for temporary guardianship. The Certificate of Administrator (or representative) of U.S. Department of Veterans Affairs is being filed at this time. 10. The following person is nominated as guardian: See attached. Type of Guardian Name & Address Phone Guardian of the Person             Guardian of the Estate             Temporary Guardian of the Person             Temporary Guardian of the Estate             Standby Guardian of the Person             Standby Guardian of the Estate             11. A sworn and notarized Statement of Acts by Proposed Guardian and Consent to Serve: accompanies this petition. will be filed at least 96 hours before the hearing. will be provided, if required for temporary guardianship. 12. A. The approximate value of individual’s property is: See attached. General Description Amounts General Description Amounts Cash/Bank Accounts: $       Other Liquid Assets: $       Real estate: $       Other Assets : $       B. Assets of individual previously derived from or benefits of individual now due and payable from U.S. Department of Veterans Affairs are: none       See attached . C. The individual is receiving public benefits, including medical assistance, SSI, SSDI or long term community options program benefits: No Yes, type and amount:       D. Any other claim, income, compensation, pension, insurance or allowance to which the individual may be entitled is none. as follows: See attached. General Description Amounts (monthly) General Description Amounts (monthly) Social security $       Investment Income $       Pension $       Other $       Disability $       Other $       FOR PERMANENT GUARDIANSHIP (Complete #13, #14 and #15) 13. The individual is alleged to be incompetent as a result of: developmental disabilities. serious and persistent mental illness. GN-3100, 01/07 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency §§50.06, 54.10(3), 54.34, 54.50, 54.852(7) and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 6 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency Page 3 of 6 Case No. degenerative brain disorder. other like incapacities. A guardian is requested to be appointed for the individual based upon the following standards : A. The individual is at least 17 years and 9 months. 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, education, support services, health care, assistive devices, or other means that the individual will accept. C. For purposes of appointment of guardian of the person , because of impairment, the individual is unable effectively to receive and evaluate information or to make or communicate decisions to such extent that the individual is unable to meet the essential requirements for the individual’s physical health and safety. D. For purposes of appointment of guardian of the estate , because of an impairment, the individual is unable effectively to receive and evaluate information or to make or communicate decisions related 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. 14. The specific nature of the individual’s alleged incapacity is as follows: See attached.       15. I petition the court to appoint a permanent guardian because the individual has incapacity in part or in full to exercise specific rights. The specific rights of the individual that I seek to have removed or transferred to the permanent guardian of person and the specific authority sought by me for the permanent guardian of person and the permanent guardian of the estate are as follows: A. Rights to be removed from the individual Some of these rights may be exercised with consent of the guardian of the person, as stated in section B. consent to marriage. execute a will. serve on a jury. apply for an operator’s license, a hunting, fishing or other license issued under ch 29, or a credential as defined in §440.01(2), Wisconsin Statutes       . consent to sterilization. consent to organ, tissue, or bone marrow donation. register to vote or vote in an election. B. Rights the individual may exercise with the consent of the guardian of the person consent to marriage. apply for an operator’s license, a hunting, fishing or other license issued under ch 29, or a credential as defined in §440.01(2), Wisconsin Statutes       . consent to sterilization. consent to organ, tissue, or bone marrow donation. C. Powers and extent of assignment to the guardian of person consent to medical examination and treatment, and consent to voluntary medication, including psychotropic medication that is in the individual’s best interests, if the guardian has first made a good-faith attempt to discuss with the individual the individual’s voluntary receipt of the psychotropic medication and the individual does not protest. Guardian of person’s authority: full limited       GN-3100, 01/07 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency §§50.06, 54.10(3), 54.34, 54.50, 54.852(7) and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 6 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency Page 4 of 6 Case No. authorize individual’s participation in an accredited or certified research project if the research project might help the individual, or others if minimal risk of harm Guardian of person’s authority: full limited       authorize individual’s participation in research that might not help the individual but might help others if greater than minimal risk of harm to the individual but evidence indicates individual would have elected to participate Guardian of person’s authority: full limited       consent to experimental treatment in the individual’s best interests Guardian of person’s authority : full limited       consent to receipt by individual of social and supported living services Guardian of person’s authority: full limited       consent to release of confidential records other than court, treatment, and patient health care records and redisclosure as appropriate Guardian of person’s authority: full limited       power to make decisions related to mobility and travel Guardian of person’s authority: full limited       power to choose providers of medical, social, and supported living services Guardian of person’s authority: full limited       power to make decisions regarding educational and vocational placement and support services or employment Guardian of person’s authority: full limited       power to make decisions regarding initiating a petition for termination of marriage Guardian of person’s authority: full limited       power to receive all notices on behalf of individual Guardian of person’s authority: full limited       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 individual in any legal proceedings pertaining to the property, unless the guardian of the person is also the guardian of the estate Guardian of person’s authority: full limited       power to apply for protective placement or for commitment Guardian of person’s authority: full limited       power to have custody of the individual, if an adult, and the power to have care, custody, and control of the individual, if a minor Guardian of person’s authority: full limited       other specific powers, see attached. D. Appointment of guardian of the estate and extent of powers Appoint a guardian of the estate with: 1. duties under §54.19; 2. standard powers under §54.20(1), and 3. powers that do not require court approval under §54.20(3) GN-3100, 01/07 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency §§50.06, 54.10(3), 54.34, 54.50, 54.852(7) and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 6 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency Page 5 of 6 Case No. Guardian of estate’s authority: full limited       Authorize the guardian of the estate to exercise additional powers requiring court approval under §54.20(2), other than to make gifts, as follows:       Dispense with bond and order deposit of 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 the ward, and payable only upon further order of the court. Dispense with an appointment of a guardian of the estate and transfer the individual’s funds of $50,000 or less under one of the alternatives for small estates under §54.12(1), WI Statutes, as follows:       FOR TEMPORARY GUARDIANSHIPS (Complete #16 through #20): 16. There has been no temporary guardianship of the individual in effect within the last 90 days . 17 . The individual’s particular situation, including the needs of the individual’s dependents, if any, requires immediate appointment of a temporary guardian for the following specific reasons:       See attached. 18. I petition the court for the appointment of a temporary guardian with authority limited to those acts that are reasonably related to the reasons for appointment. The authority requested for the temporary guardian is as follows:       See attached. 19. I petition the court to hold a hearing within 48 hours . Good cause exists to support this request for the following reasons:       See attached. 20. A petition for appointment of a permanent guardian of the person or estate is NOT filed with this request because:       S ee attached. I REQUEST THAT THE COURT: 1. Order a hearing on this petition. 2. Make appropriate findings and appointments as requested above. 3. Award appropriate fees and costs. GN-3100, 01/07 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency §§50.06, 54.10(3), 54.34, 54.50, 54.852(7) and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 5 of 6 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency Page 6 of 6 Case No. Subscribed and sworn to before me on       Notary Public/Court Official My commission expires:       Signature of Petitioner       Name Printed or Typed       Address       Name of Attorney       Address       Telephone Number       Bar Number       GN-3100, 01/07 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency §§50.06, 54.10(3), 54.34, 54.50, 54.852(7) and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 6 of 6