FORM SUMMARY Name of Form: Letters of Guardianship of the Person Due to Incompetency Form Number: GN-3200 Statutory Reference: §§54.18, 54.25, 54.46(5), 54.52 and Chapter 54, Wisconsin Statutes Benchbook Reference: GA-1, GA-2 Purpose of Form: Authorization to serve as guardian of the person. Who Completes It: Petitioner or attorney. Distribution of Form: Original to court. Copies to Guardian and to interested persons as required by statutes. Accompanying Forms: New Form/Modification: Modified; last update 04/08. Modifications: Added provision to indicate whether the power of attorney for healthcare is revoked or limited. Changed to clarify and simplify form. Comments: There are separate forms for Letters for Guardianship of the Person (GN-3200) and Estate (GN-3210) and Temporary Guardianship of the Person (GN-3260) and Estate (GN-3265) and Guardianship of a Person of a Minor (GN-3340) and Estate of a Minor (GN-3345). About this Form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court’s Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 02/11/2010 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com For Official Use COUNTY STATE OF WISCONSIN, CIRCUIT COURT, Amended IN THE MATTER OF Letters of Guardianship of the Person Due to Incompetency Case No. Date of Birth To: Address: You are appointed co-guardian of the person. guardian This is an appointment as a successor guardian. You are appointed stand-by guardian and your authority to act commences on (Date) . and continues through (Date) Power of attorney for healthcare is revoked or limited as follows: You are issued Letters of Guardianship of the Person with the following powers or limitations: 1. Co-Guardians must agree with each other when making decisions on behalf of the individual subject to unless otherwise ordered by the court as follows: guardianship . 2. The successor guardian is authorized to exercise powers as previously authorized or modified for this individual subject to guardianship. 3. The individual retains the right to exercise the following right(s) only with consent of the guardian of person to: consent to marriage. apply for an operator’s license, a hunting, fishing or other license issued under ch. 29, or a credential as defined in §440.01(2), Wisconsin Statutes: consent to sterilization. consent to organ, tissue, or bone marrow donation. The guardian of the person has all the duties specified under §54.25(1). 4. The guardian of the person is authorized to exercise the following specific powers in part or in full: If a power is granted, the box to the far left must be marked. Marking only box (1) or (2) has no effect and the guardian may not exercise the power. ab. Except as otherwise limited by Wisconsin Statute 54.25(2)(d)2.ab., the power to give an informed consent to the voluntary receipt by the guardian's ward of a medical examination, medication, including any appropriate psychotropic medication, and medical treatment that is in the ward's best interest, if the guardian has first made a good-faith attempt to discuss with the ward the voluntary receipt of the examination, medication, or treatment and if the ward does not protest. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. ac. Except as otherwise limited by Wisconsin Statute 54.25(2)(d)2.ac., the power to give informed consent, if in the ward's best interests, to the involuntary administration of a medical examination, GN-3200, 02/10 Letters of Guardianship of the Person Due to Incompetency §§54.18, 54.25, 54.46(5), 54.52 and Chapter 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Letters of Guardianship of the Person Due to Incompetency b. c. d. e. f. g. h. i. j. k. Page 2 of 3 Case No. medication other than psychotropic medication, and medical treatment that is in the ward's best interest. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to authorize individual’s participation in an accredited or certified research project if the research project might help the individual, or others if minimal risk of harm. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to authorize individual’s participation in research that might not help the individual but might help others if greater than minimal risk of harm to the individual but evidence indicates individual would have elected to participate. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to consent to experimental treatment in the individual’s best interests. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to give informed consent to receipt by individual of social and supported living services. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to give informed consent to release of confidential records other than court, treatment, and patient health care records and redisclosure as appropriate. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to make decisions related to mobility and travel. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. [Intentionally omitted to correspond with statute.] The power to choose providers of medical, social, and supported living services. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to make decisions regarding educational and vocational placement and support services or employment. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. The power to make decisions regarding initiating a petition for termination of marriage. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. GN-3200, 02/10 Letters of Guardianship of the Person Due to Incompetency §§54.18, 54.25, 54.46(5), 54.52 and Chapter 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Letters of Guardianship of the Person Due to Incompetency Page 3 of 3 Case No. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. l. The power to receive all notices on behalf of individual. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. m. The power to act in all proceedings as an advocate of the individual, except the power to enter into a contract that binds the individual or the individual’s property or to represent the individual in any legal proceedings pertaining to the property, unless the guardian of the person is also the guardian of the estate. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. n. The power to apply for protective placement or for commitment. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. o. The power to have custody of the individual, if an adult, and the power to have care, custody, and control of the individual, if a minor. Choose (1) or (2): . (1) Individual retains limited capacity and the power to: Guardian of the person to exercise power not retained by individual. (2) Individual lacks evaluative capacity in full. Guardian of the person to exercise full power. p. Other specific powers: See attached 5. The guardianship of the person terminates when the individual dies, when terminated by the court or when provided by law. These Letters of Guardianship of the Person supersede any previously issued Letters of Guardianship of the Person. BY THE COURT: (SEAL) Circuit Court Judge / Circuit Court Commissioner Name Printed or Typed Date Name of Attorney/Petitioner Address Telephone Number Bar Number GN-3200, 02/10 Letters of Guardianship of the Person Due to Incompetency §§54.18, 54.25, 54.46(5), 54.52 and Chapter 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com