STATE OF WISCONSIN, CIRCUIT COURT, For Official Use COUNTY IN THE INTEREST OF Petition for Appointment of Guardian/ Notice of Hearing a person under the age of 18. Case No. Date of Birth I STATE ON INFORMATION AND BELIEF THAT: 1. The petitioner is: the child. the child’s guardian ad litem. the child’s guardian. the child’s legal custodian. the child’s parent. the department. a county department. the person with whom the child is placed and who is nominated as the child’s guardian in this petition. the licensed child welfare agency assigned primary responsibility for providing services to the child under a court order or licensed to accept guardianship. a person representing the interests of the public under §48.09, Wis. Stat. a person with whom the child has resided who has acted as a parent. Child’s Address 2. Father’s Name and Address Father is no longer living Mother’s Name and Address Mother is no longer living Guardian’s Name and Address Legal Custodian’s Name and Address 3. 4. 5. 6. 7. 8. 9. The child was adjudicated in need of protection or services under § on (Date) and has been placed, or continued in a placement, outside of his or her home pursuant to one or more court orders under § . The facts and circumstances which establish that the conditions specified under §48.977(2)(b)-(f) are met are: See attached These proceedings are are not subject to the uniform child custody jurisdiction and enforcement act under ch. 822. The child is is not may be subject to the federal Indian Child Welfare Act. Tribe/address: The person with whom the child is placed and nominated as the guardian of the child is The person representing the interests of the public under §48.09, Wis. Stats., is The agency primarily responsible for providing services to the child under a court order is 10. The department or county department has determined that the proposed guardian is eligible to receive monthly subsidized guardianship payments under §48.623(1), Wis. Stats., and it is requested that the court confirm those determinations. Attach department eligibility statement. I request that (Name) be appointed guardian of the child. Signature of Petitioner Name Printed or Typed Date This case is scheduled for a plea hearing as scheduled below: NOTICE OF HEARING Date Time Location (Include Room Number) Presiding Judge DISTRIBUTION: 1. Court-Original; 2. Parties; 3. Tribe (if any) JC-1605, 08/11 Petition For Appointment of Guardian/Notice of Hearing §§48.623(1), 48.831 and 48.977, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. www.FormsWorkFlow.com