JC-1612, 02/18 Petition for Protection or Care of an Unborn Child (Chapter 48) 24724748.133 and 48.255(1m), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF J. Doe, an unborn child, and the unborn child's expectant mother Date of Birth Petition for Protection or Care of an Unborn Child (Chapter 48) Case No. I STATE ON INFORMATION AND BELIEF THAT THE FOLLOWING IS TRUE: [If unknown or cannot be ascertained, so state] 1. The estimated gestational age of the unborn child is weeks. Expectant Mother's Street and City Address If expectant mother is a child (17 or under) Parent 1 's Name and Address Parent 1's Birthdate Parent 2 's Name and Address Parent 2's Birthdate Name and Address of Guardian, Legal Custodian, Spouse, if any If expectant mother is an adult (18 or over): Spouse's name and address, or if no spouse, nearest relative's name and add ress Expectant mother in temporary physical custody? No Yes: Date/Time: Where held: Not disclosed - threat of imminent danger to unborn child/expectant mother/physical custodian. Unborn child , when born, may be subject to federal Indian C hild W elfare A ct? (25 USC 24724719 0 1 - 1963) No Un determined (Explain: ) Yes: Tribe/address: 2. The unborn child is in need of protection or care. 3. The expectant mother is in need of supervision, services, care or rehabilitation. 4. The reliable and credible information which forms the basis for the allegations, including the conduct or circumstances to be considered by the court is See attached I request adjudication and entry of an appropriate dispositional order. DISTRIBUTION: 1. Court 2. Expectant mother 3. Parents of expectant mother (if a child) 4. Guardian/Legal custodian/Physical custodian/GAL of expectant mother 5. GAL of unborn child 6. Tribe (if any) Signature: District Attorney/Corporation Counsel Counsel /GAL of Expectant Mother GAL of Unborn Child Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com