COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : STATE OF WISCONSIN, CIRCUIT COURT, WASHINGTON COUNTY, PROBATE Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) DOCTOR’S CERTIFICATE IN THE INTEREST OF -against- ____________________________________ (Print Name) Alleged Incompetent 1. 2. : By Dr.___________________________ (Print Name) : : I certify that I am a duly licensed physician, licensed to practice in the State of Wisconsin. Defendant(s) : . .I. examined. the . . . . . .person,. who. is._____ . . . . . of. age,. at . . . . . . . . . . . . . . above . . . . . . . . . . . . . . years . . . . . . _____________________________, in ____________________ County, Wisconsin, on _________________, 200___. 3. 4. 5. 6. As a result of such examination, I certify that my diagnosis of subject’s mental condition is that subject is incompetent and THE STATE substantially incapable of: THE PEOPLE OF is, therefore, OF NEW YORK managing property caring for self TO and that he/she is incompetent by reason of: infirmities of aging developmental disabilities other like incapacities GREETINGS: such examination, I do further certify that the subject’s: As a result of mental condition does not warrant a finding of limited incompetency WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before mental condition warrants a finding of limited incompetency and that her/she is competent to , the Honorable exercise the following legal rights: the at Court located at County of right to vote in room , on theright to marry day of , 20 , at o'clock in the noon, and at any recessed right give evidence as a witness in this action on or adjourned date, to testify andto obtain a motor vehicle operator’s license the part of the right to testify in any proceeding right to make a Will right to hold or convey property right to contract Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalfright to ________________________________ this subpoena was issued for a maximum penalty of $50 and all damages sustained as a As a result of the examination, result of your failure to comply. I have determined that the subject is capable incapable Witness, Honorable , one of the Justices of the of understanding the advantages and disadvantages of medication, after advantages, disadvantages and Court in County, , 20 alternatives have been explained. day of My opinion is based upon the following findings and evaluation: (Attorney must sign above and type name below) Attorney(s) for **ALERT** Strike out No. 7 when not applicable: 7. As a result of such examination, I do further certify that subject’s condition is such that he/she would be of no assistance to the Court and that it would be detrimental to subject’s welfare and not proper to remove subject so that he/she could appear in Court for the proceedings for the appointment of a guardian. Office and P.O. Address Telephone No.: Signature Facsimile No.: Post Office Address E-Mail Address: Mobile Tel. No.: GN-3000 – (Local) Washington County - Doctor’s Certificate - Revised 4/2/02 (Formerly Form 916) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) Legal definition of INCOMPETENT, pursuant to Wisconsin Statutes, 880.01(4): -against- : “Incompetent” means a person adjudged by a court of record to be substantially : incapable of managing his property or caring for himself by reason of infirmities of aging, developmental disabilities, or other like incapacities. : Legal definition of grounds of mental incompetence, pursuant to Wisconsin Statutes: Defendant(s) : ...................................................... A. INFIRMITIES OF AGING – Section 880.01(5): “Infirmities STATE OF NEW organic THE PEOPLE OF THEof aging” meansYORK brain damage caused by advanced age TO B. or other physical degeneration in connection therewith to the extent that the person so afflicted is substantially impaired in his ability to adequately provide for his own care or custody. DEVELOPMENTAL DISABILITIES – Section 880.01(2) GREETINGS: “Developmentally disabled business means any individual having a each of you WE COMMAND YOU, that all person”and excuses being laid aside, you and disability attend before attributable to mental retardation, cerebral palsy, epilepsy, autism or another , the Honorable at the Court located at County ofneurological condition closely related to mental retardation or requiring which has in room treatment similar to that required for mentally retarded individuals,noon, and at any recessed , on the day of , 20 , at o'clock in the or adjourned date, to testify and give evidenceto continuein this action on the substantially continued or can be expected as a witness indefinitely and part of the impairs the individual from adequately providing for his or her own care or custody and constitutes a substantial handicap to the afflicted individual. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to C. OTHER behalf INCAPACITIES – Section 880.01(8) the party on whose LIKE this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. “Other like incapacities” means those conditions incurred at any age which Witness, Honorable are the result of accident, organic brain damage, mental, onephysical or of the Justices of the Court in disability, continued consumption or absorption of substances, producing a County, day of , 20 condition which substantially impairs an individual from providing for his own care or custody. (Attorney must sign above and type name below) Legal definition of NOT COMPETENT TO REFUSE PSYCHOTROPIC MEDICATION, pursuant to Wisconsin Statutes 880.01(7m): Attorney(s) for “Not competent to refuse psychotropic medication” means that, because of chronic mental illness, as defined in s. 51.01(3g), a person is incapable of expressing an understanding of the advantages and disadvantages of accepting treatment offered, after the advantages, disadvantages and alternatives have been explained to that Office and P.O. Address person. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com