GN-3121, 05/18 Certificate of Service on Individual (Guardianship, Protective Placement or Protective Services) 24724754.38(2)(a) and 55.09(1), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Certificate of Service o n Individual (Guardianship, Protective Placement or Protective Services) Case No. UNDER OATH, I STATE: I am an adult resident of the State of Wisconsin and not a party to the action or a named interested person in the action . I her e by certify that on [Date] at [Time] a.m./p.m. , I duly served the above - named individual residing at with the following documents . Documents provided: Order and Notice of Hearing for hearing on Petition for Temporary Guardianship P etition for Temporary/Permanent Guardianship Incapacitation Statement Consent to Serve as Temporary Gu ardian Order Appointing Guardian ad Litem or Attorney Statement of Acts by Proposed Guardian and Consent to Serve as Guardian Petition for Protective Placement Petition for Permanent Guardianship Other documents I further certify that I informed the individual of the complete contents of the documents. At the time of service, I did place upon it the date, time, manner and my name, leaving a true and correct copy thereof, and that I knew the person so served to be the proposed ward/ward (or other) mentioned and named therein. A copy of the N otice so cer tified is returned to the C ourt with this document. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Signature Name Printed or Typed Address Date NUMBER OF ATTEMPTS : NUMBER OF ADDRESSES AT TEMPTED: (if more than one) SERVICE FEE $ American LegalNet, Inc. www.FormsWorkFlow.com