STATE OF WISCONSIN, CIRCUIT COURT, Name: Last Date of Birth: First Middle Name/Initial COUNTY Amended For Official Use Adjudication and Prohibited Possession of Firearms and Caregiver License Restriction Report Case No. WI SID No. Arrest Tracking No. This report is used to provide the Wisconsin Crime Information Bureau with information required by §§48.685, 51.20(13)(cv)4, 51.45(13)(i)4, 54.10(3)(f)4, 55.12(10)(d), and 938.396(2g)(n) of the Wisconsin Statutes. Submit one copy to the Crime Information Bureau, Attn: Handgun Hotline, P.O. Box 2718, Madison, WI 53701-2718 or email to: wihotline@doj.state.wi.us or fax to (608) 264-6200. If you have questions or require assistance, call (608) 267-2776. Note: The following data elements are: MANDATORY DATA OPTIONAL DATA Name (Last, First, Middle Initial) Hair, Eyes, Height, Weight, Arrest Tracking Number and Sex and Race Wisconsin State Identification Number. Date of Birth Court Case Number Furnishing this information, when known, will assist in the Name and Title of the person submitting the report identification of the person prohibited from possession of a firearm Date of Report and from caregiver employment/ licensure. County Court ORI Statute number(s) if the person is prohibited from caregiver employment/licensure DESCRIPTOR INFORMATION Sex Race Height Weight Eye color Hair color COURT INFORMATION Juvenile Adjudication: (Check all boxes that apply) The above person is prohibited from possessing a firearm as a juvenile adjudicated delinquent for an act that would be a felony if committed by an adult. [§§ 938.396(2g)(n) and 941.29(1)(bm), Wis. Stats.] The above person is prohibited from caregiver employment/licensure as a juvenile adjudicated delinquent of a serious crime, WI Statute number(s) . [§§48.651(3) and 48.685(4m), Wis. Stats.] Date of Adjudication: / / Month Day Year Commitment, Guardianship or Protective Placement: The above individual was committed under §51.20(13)(a)3.-5., Wis. Stats., and ordered not to possess a firearm. [§§51.20(13)(cv)1 and 941.29(1)(e), Wis. Stats.] The above individual was committed under §51.45(13)(g)1, WI Stats. and ordered not to possess a firearm. [§§51.45(13)(i)1, Wis. Stats.] A guardian of the person was appointed for the above individual under §54.10(3), Wis. Stats., and the individual was ordered not to possess a firearm. [§54.10(3)(f), Wis. Stats.] The court ordered protective services or protective placement for the above individual under §§55.08 and 55.12, Wis. Stats., and the individual was ordered not to possess a firearm. [§55.12(10)(a), Wis. Stats.] Effective Date of Order: / / Month Submitted By ­ Name & Title Day Year County Date of Report (Month/Day/Year) Court ORI GF-220, 08/11 Adjudication and Prohibited Possession of Firearms and Caregiver License Restriction Report (DJ-LE-FH9) §§48.685, 51.20(13)(cv)4, 51.45(13)(i)4, 54.10(3)(f)4, 55.12(10)(d), and 938.396(2g)(n), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. www.FormsWorkFlow.com