GN-4000, 01/09 Statement of Emergency Protective Placement 24755.135, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Statement of Emergency Protective Placement Case No. 1. I am a sheriff or police officer. a fire fighter. a guardian. an authorized representative of the county department or an agency with which it contracts under 24755.02(2), Wis. Stats. 2. It appears probable that the individual is so totally incapable of providing for own care or custody as to create a substantial risk of serious physical harm to the individual or others as a result of a developmental disability, degenerative brain disorder, serious and persistent mental illness or other like incapacities if not immediately placed in an appropriate medical or protective placement facility. The specific factual information that is the basis for the emergency protective placement, based on personal observation or a reliable report by a person identified to me, is as follows: See attached 3. A Petition for Protective Placement is being filed with this statement. A Petition for Guardianship is also being filed unless the individual is A. currently under guardianship; OR B. a minor who is alleged to have a developmental disability. 4. The individual was detained at , [Name of Facility] , on [Date] , at [Time] a.m. p.m. City County State Zip code Signature of Person Making Placement Name of Department and Address Name Printed or Typed Telephone Number DISTRIBUTION: 1. Court 2. Individual 3. Facility 4. Guardian ad Litem 5. Department 6. Other: American LegalNet, Inc. www.FormsWorkFlow.com