STATE OF WISCONSIN, CIRCUIT COURT, State of Wisconsin -vs, Defendant Name COUNTY Referral by Department of Corrections to Sentencing Court §302.113(9g), Wis. Stats. (Geriatric/Extraordinary Health Condition) Case No. Date of Birth 1. Attached is the inmate's Petition to Modify Bifurcated Sentence. The Program Review Committee has approved this petition for referral to the sentencing court. The Program Review Committee has determined that the public interest would be served by a modification of the inmate's bifurcated sentence in the manner provided in §302.113(9g)(f), Wis. Stats. (See attached decision of Program Review Committee.) The Department of Corrections requests that the court conduct a hearing on this petition. The inmate is eligible under §302.113(9g)(i), Wis. Stats. A. The inmate is 65 years of age or older and has served at least 5 years of the term of confinement in prison. OR B. The inmate is 60 years of age or older and has served at least 10 years of the term of confinement in prison; OR C. The inmate has an extraordinary health condition, and has attached to the petition affidavits from two (2) physicians setting forth a diagnosis that the inmate has an extraordinary health condition. The inmate has requested appointment of an attorney. Department of Corrections: 2. 3. 4. Signature DISTRIBUTION: 1. Court 2. Department of Corrections 3. District Attorney 4. Inmate/Attorney Name Printed or Typed Date CR-255, 08/11 Referral by Department of Corrections to Sentencing Court §302.113(9g), Wis. Stats. DOC-2253 §302.113(9g), Wisconsin Statutes American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material.