GN-3100, 05/19 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency 24724750.06, 53.23, 54.01(17)(a), 54.10(3), 54.34, 54.44(1), 54.47, 54.50, 54.852(7), and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 5 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Petition for Temporary Permanent Guardianship Due to Incompetency Case No. UNDER OATH, I STATE: 1. I am interested as a relative. I am related to the individual as . a public official. My authority to act as petitioner is . Other: 2. This Petiti on is filed in the county in which the individual resides. is physically present. . Other: 3. The individual lives in County, State of , [Phone Number] mailing address is [Street, City, State, Zip] . 4. The name and mailing address of the person or institution, if any, that has care and custody of the individual or the facility, if any, that is providing care to the individual is: Name Phone Number Mailing Address [Street] [City, State, Zip] This Petition for Guardianship is filed with a Petition for Protective Placement prior to transfer of the individual directly from a hospital to a nursing facility or community - b ased residential facility under 24750.06, Wis. Stat s. 5. The names and mailing addresses of all interested parties (including the petitioner and Corporation Counsel) and all others entitled to notice are as follows: See attached Name Relationship Mailing Address [Street, City, State, Zip] 6 . The individual is married and has children who are not children of the current spouse. 7. The individual does does not have a current, valid Financial Durable Power of Attorney activated. Financial Agent Name Phone Number Mailing Address [Street] [City, State, Zip] See attached does does not have a current, valid Power of Attorney for Health C are activated. Health Care Agent Name Phone Number Mailing Address [Street] [City, State, Zip] See attached does does not have other advance planning to avoid guardianship. American LegalNet, Inc. www.FormsWorkFlow.com GN-3100, 05/19 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency 24724750.06, 53.23, 54.01(17)(a), 54.10(3), 54.34, 54.44(1), 54.47, 54.50, 54.852(7), and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 5 If the above - named power of attorney or advanc ed planning exist, guardianship is still necessary because . See attached 8. I am not aware of a guardianship or other related proceeding or ordered proceeding involving the individual in another state or county. aware of a guardianship or other related proceeding or ordered proceeding involving the individual in another state or county. The details of the guardianship, or other related proceedings of which I am aware are as follows: See attached guardian(s) appointed in Wisconsin: [Name and county where appointed] guardian(s) appointed out - of - state: [Name and state where appointed] 9. I nominate the following : See attached Type of Guardian Name Mailing Address [Street, City, State, Zip] Telephone Number Guardian of the Person Guardian of the Estate Temporary Guardian of the Person Temporary Guardian of the Estate Standby Guardian of the Person Standby Guardian of the Estate 10. A sworn and notarized Statement of Acts by Proposed Guardian and Consent to Serve accompanies this Petition. will be filed at least 96 hours before the hearing. will b e provided, if required by the C ourt for temporary guardianship. 11. A. The approximate value of the See attached General Description Amounts General Description Amounts Cash/Bank Accounts: $ Other Liquid Assets: $ Real E state: $ Other Assets : $ B. The assets of individual previously derived from or benefits of individual now due and payable from U.S. Department of Veterans Affairs are none See attached C. The individual receives public benefits, including medical assistance, SSI, SSDI or long term community options program benefits. No Yes, type and amount: . D. Any other claim, income, compensation, pension, insurance or allowance to which the individual may be entitled is none. as follows: See attached General Description Amounts [Monthly] General Description Amounts [Monthly] Social S ecurity $ Investment Income $ Pension $ Other: $ Disability $ Other: $ FOR PERMANENT GUARDIANSHIP 12. A. A Report of Examination by a Physician or Psychologist is filed with this Petition. will be filed with the court and provided by the petitioner to the guardian ad litem and the attorney for the individual at least 96 hours before the time of the hearing. B . A Certificate of Administrator (or representative) of U.S. Department of Veterans Affairs is filed with this Petition. 13. I allege that the individual is incompetent and a guardian should be appointed because: A. the individual will be at least 17 years and 9 months of age as of the date of the hearing. B. the individual has the following impairment: a developmental disability. degenerative brain disorder. serious and persistent mental illness. other like incapacities. American LegalNet, Inc. www.FormsWorkFlow.com GN-3100, 05/19 Petition for Temporary Guardianship and/or Permanent Guardianship Due to Incompetency 24724750.06, 53.23, 54.01(17)(a), 54.10(3), 54.34, 54.44(1), 54.47, 54.50, 54.852(7), and Ch. 54, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 5 C. decision - making or communication is unable to be met effectively and less restrictively through appropriate and reasonably available training, education, support services, health care, assistive devices, or other means that the individual will accept. D. (For appointment of guardian of the person. ) The individual, because of impairment, is unable effectively to receive and evaluate information or to make or communicate decisio ns to such extent that E. (For appointment of guardian of the est ate. ) The individual, because of an impairment, is unable effectively to receive and evaluate information or to make or communicate decisions related to fo llowing applies: (1) The individual has property that will be dissipated in whole or in part; or (2) , or (3) The individual is unable to prevent financial exploitation. 14. The ged incapacity is as follows: See attached 15 . GUARDIAN OF THE PERSON I request the appointment of a g uardian of the p erson . If granted, I understand that this may result in a s pursuant to 247 54.10(3)(f), Wis. Stats. A. Rights to be removed in full. If removed, these rights may not be exercised by any person. I request that the court declare the indivi dual has incapacity to exercise the right to (1) execute a will. (2) serve on a jury. (3) register to vote or to vote in an election. B. Rights to be removed in full or exercised only with consent of guardian of person. The individual has incapacity or limited capacity to exercise the following rights: (If any box is not checked, the individual retains that right in full.) Individual may not exercise this right. Remove right in full. Individual may exercise only with the consent of the guardian of the person. (1) consent to marriage. (3) apply for a fishing license. (4) apply for a license under Ch. 29, Wis. Stats., other than fishing. (5) apply for any other license or credential under 24754.25(2)(c)1.d., Wis. Stats. Specifically: (6) consent to sterilization. (7) consent to organ, tissue, or bone marrow donation. C. Powers to be transferred to g uardian of the p erson in full or in part . I request the court transfer to the guardian of the person to exercise the power in full or in part to: 1.A. give informed consent to the voluntary receipt by the individual of a medical examination, medication, including any appropriate psychotropic medication, and medical treatment that is in the individual's best interest, if the guardian has first made a good - faith attempt to discuss with the individual the voluntary receipt of the examination, medication, or treatment and if the individual does not protest. Full Transfe