CR-261, 11/11 Verification of Time Served 247973.195, Wis. Stats. 247973.195, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY State of Wisconsin, Plaintiff - vs - Name Date of Birth Amended Verification of Time Served 247 973.195, Wis. Stats. Case No. Count No. 1. years, months, days. 2. The initial term of confinement on this count is years, months, days. 3. The initial term of extended supervision on this count is years, months, days. 4. All subsequent terms of confinement ordered on this count : 5. The initial term of confinement has been adjusted due to disciplinary dispositions (bad time) to increase the initial term of confinement on this count by years, months, days. The initial term of extended supervision has been a djusted to decrease the initial term of extended supervision by the same amount. (This adjusted period of confinement must be added to the initial term of confinement for purposes of making the percentage calculation.) 6. The subsequent term of confinement has been adjusted due to disciplinary dispositions (bad time) to increase the subsequent term of confinement on this count by years, months, days. The subsequent term of extended supervision h as been adjusted to decrease the subsequent term of extended supervision by the same amount. (This adjusted period of confinement must be added to the subsequent term of confinement for purposes of making the percentage calculation.) 7. The inmate has s erved on this count a total of years, months, days in confinement. 8. The inmate does does not have another sentence(s). (Attached are copies of judgment(s) of conviction of any other sentences(s).) 9. This information is accurate as of the date of signing. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Department of Corrections Representative Name Typed or Printed Date DISTRIBUTION: 1. Court American LegalNet, Inc. www.FormsWorkFlow.com