CR-210A, 05/17 Request for Appointment of Special Prosecutor under Chapter 978 247978.045, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Request for Appointment of Special Prosecutor under Chapter 978 I am the district attorney for County . On [Date] , I submitted an affidavit to the Department of Administration attesting that one or more of the following conditions exists for appointment of a special pros ecutor: 1. There is no district attorney for the county. 2. The district attorney is absent from the county. 3. The district attorney, or a deputy or assistant district attorney, is on parental leave. 4. The district attorney has acted as an attorney for a party accused in relation to the matter of which the accused stands charged and for which the accused is to be tried. 5. The district attorney is near of kin to the party to be tried on a criminal charge. 6. The district attorney is unable to attend to duties due to a health issue or has a mental incapacity that impairs ability to perform duties. 7. The district attorney is serving in the U.S. armed fo rces. 8. The district attorney is charged with a crime and the governor has not acted under 24717.11, Wis. Stats. 9. The district attorney determines that a conflict of interest exists regarding the district attorney or the district attorney staff. District Attorney Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com