GN-4080, 05/19 Petition for Annual Review of Protective Placement 24724746.279, and 55.18(1),(a),(2), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Petition for Annual Review of Protective Placement Case No. UNDER OATH, I STATE : 1. I am a representative of the county department 2. The ward resides at Address: Name of facility and contact person and phone number (if any) Facility Name: Contact Person Name: Contact Person phone number: Guardian(s) name: Guardian(s) Phone number(s): 3. The ard was filed or will be filed. A copy of this r eport was t under any activated Power of Attorney for Health Care. 4 . This ward has developmental disabilities and is currently protectively placed in an intermediate faci lity or nursin g facility. The p lan for providing home or community - based care in a non - institutionalized community setting, intermediate facility or nursing facility which would be the most integrated setting appropriate to the needs of this ward was filed or will be filed. A copy of this p I REQUEST THE COURT : 1. Review the status of the protective placement of the ward. 2. Other: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Address Date DISTRIBUTION: 1. Court 2. Ward 3. 4. Corporation Counsel 5. 6. Guardian ad litem 7. 8. Facility in which the ward resides 9. County Department of Human Services/Social Worker American LegalNet, Inc. www.FormsWorkFlow.com