ME-903, 05/19 Petition for Examination 24751.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE CONDITION OF Name of Subject Date of Birth Petition for Examination Case No. This document was drafted by County Corporation Counsel [Name] as required by law. UNDER OATH , we petition the Court to examine the condition of the subject, who resides in [County] at , and allege that: A. The subject is mentally ill, drug dependent, or developmentally disabled and a proper subject for treatment because: See attached B. The subject is dangerous to himself/herself or others as defined by 247 51.20(1)(a)2 . , Wis. Stats. My belief is based on specific and recent dangerous acts, attempts, threats, omissions, and/or statements made by the subject as observed by me or reliably reported to me as stated below: Dangerous Behavior When: Where: Describe Behavior: See attached C. The following petitioner(s) has personal knowledge of the conduct of the subject: Name Address Telephone Relationship to Subject 1) 2) 3) D. The following petitioner(s) does not have personal knowledge of the conduct of the subject but bases his/her belief on the following: Name Address Telephone Relationship to Subject 1) Basis for Belief: 2) Name Address Telephone Relationship to Subject Basis for Belief: E. In addition to the petitioners, the following person(s) may testify in support of this Petition: Name Address Telephone American LegalNet, Inc. www.FormsWorkFlow.com ME-903, 05/19 Petition for Examination 24751.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 F. The names and post office address of subject's: (If unknown or inapplicable, so state.) Spouse Post Office Address Adult Children Post Office Address Parents or Guardian Post Office Address Custodian Post Office Address Brothers/Sisters Post Office Address Person(s) With Whom Subject Resides Post Office Address State of County of Subscribed and sworn to before me on Notary Public/Court Official N ame Printed or Typed My commission/term expires: SIGNATURE OF PETITIONER NAME PRINTED OR TYPED American LegalNet, Inc. www.FormsWorkFlow.com