STATE OF WISCONSIN, CIRCUIT COURT, Name: Last Date of Birth: First Middle Name/Initial COUNTY For Official Use Adjudication and Prohibited Possession of Firearms Cancellation Report Check all boxes that apply: CANCELLATION INFORMATION Juvenile Adjudication: A court determined that the person is not likely to act in a manner dangerous to public safety and the right to possess firearms is restored. (§941.29(8), Wis. Stats.) Effective Date: Month / Day / Year Commitment, Guardianship or Protective Placement: A court determined that the circumstances regarding the: Mental commitment (§51.20, Wis. Stats.) Alcohol commitment (§51.45, Wis. Stats.) Guardianship of the Person (§54.10, Wis. Stats.) Protective services or protective placement order (§55.12, Wis. Stats.) and the individual's record and reputation indicate that the individual is not likely to act in a manner dangerous to public safety and that the granting of the petition would not be contrary to public interest.[§§51.20(13)(cv)1m.b, 51.45(13)(i)2.b, 54.10(3)(f)2.b and 55.12(10)(b)2, WI Stats.] Effective Date of Order: Month Submitted By ­ Name & Title / Day / County Year Date of Report (Month/Day/Century-Year) Court ORI Submit one copy to: 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 Retain the original copy for your records. Should you have questions or require assistance call: (608) 267-2776. GF-221, 08/10 Adjudication and Prohibited Possession of Firearms Cancellation Report (DJ-4/08LE-FH9) §§48.685, 51.20(13)(cv)1m.b, 51.45(13)(i)2.b, 54.10(3)(f)2.b, 55.12(10)(b)2 and 941.29(8), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. www.FormsWorkFlow.com