CR-254, 08/11 Petition to Modify Bifurcated Sentence 247302.113(9g), Wis. Stats. 247302.113(9g), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. DISTRIBUTION: 1. Pro gram Review Committee Petitioner Name Typed or Printed Date STATE OF WISCONSIN, CIRCUIT COURT, COUNTY State of Wisconsin, Plaintiff - vs - Name Date of Birth Amended Petition to Modify Bifurcated Sentence 247 302.113(9g), Wis. Stats. (Geriatric/Extraordinary Health Condition) Case No. 1. I was sentenced for the crime of , on [ D ate] . The total length of my bifurcated sentence on this count is years, months. My initial term of confinement in prison is years, months . My initial term of extended supervision is years, months . I was sentenced for the crime of , on [ D ate] . The total length of my bifurcated sentence on this count is years, months. My initial term of confinement in prison is years, months . My initial term of extended supervision is years, months. I was sentenced for the crime of , on [ D ate] . The total length of my bifurcated sentence on this count is years, months . My initial term of confinement in prison is years, months . My initial term of extended supervision is years, months . 2. I am not serving a sentence for a Class A or B felony. 3. I have A. not previously filed a petition for modification of bifurcated sentence. OR B. previously had a petition for modification of bifurcated sentence denied by the Program Review Committee. The denial was on [ D ate] , and it has been over one year since that denial. OR C. previously had a petition for modification of bifurcated sentence denied by the court. The denial was on [ D ate] , and it has been over one year since that denial. 4. I A. am 65 years of age or older and have served at least 5 years of the term of confinement in prison. OR B. am 60 years of age or older and have served at least 10 years of the term of confinement in prison. OR C. have an extraordinary health condition, and have attached affidavits from two (2) physicians setting forth a diagnosis that I have an extraordinary health condition. 5. (I f any) Address Telephone Fax 6. I request appointment of an attorney. 7. I request sentence modification. American LegalNet, Inc. www.FormsWorkFlow.com