ME-934, 10/09 Petition for Examination 24751.20(1) (ar) and (1) (av) 24751.20(1)(ar) and (1)(av), 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 Inmate Date of Birth Petition for Examination of a State Prison Inmate 247 51.20 (1)(ar) Case No. UNDER OATH: We petition the court to examine the condition of the subject inmate who is incarcerated at [Name of state prison] and allege that 1. the subject inmate is mentally ill, a proper subject for treatment and in need of either outpatient treatment in the prison or inpatient treatment at a state treatment facility because: Also attach required reports. 2 . a ppropriate less restrictive forms of treatment were attempted with the subject inmate and were unsuccessful , including : 3. the subject inmate has been fully informed of his/her treatment needs, available mental health services and rights under Chapter 51, Wisconsin Statutes and has had an opportunity to discuss these matters with a licensed physician or licensed psychologist. IN ADDITION, the petitioners provide the following information: 1. The subject inmatesentence is and expected date of release is . 2. The following petitioner(s) has personal knowledge of the conduct of the subject: Name Mailing Address Telephone Number Relationship to Subject a ) b ) c ) 3. The following petitioner(s) does not have personal knowledge of the conduct of the subject: Name Mailing Address Telephone Number Relationship to Subject a ) State basis for belief : Name Mailing Address Telephone Number Relationship to Subject b ) State b asis for b elief: American LegalNet, Inc. www.FormsWorkFlow.com ME-934, 10/09 Petition for Examination 24751.20(1) (ar) and (1) (av) 24751.20(1)(ar) and (1)(av), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 4. In addition to the petitioners, the following person(s) may testify in support of this Petition: Name Mailing Address Telephone Number 5. The (If unknown or inapplicable, so state.) Spouse Mailing Address Adult Children Mailing Address Parents or Guardian Mailing Address Custodian Mailing Address Brothers/Sisters Mailing Address Person(s) With Whom Subject Resides Mailing Address State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Signature of Petitioner Name Printed or Typed DISTRIBUTION: 1. Court 2. Subject 3. Parent(s)/Legal Guardian(s)/Custodian 4. Division of Disability and Elder Services 5. Treatment Facility American LegalNet, Inc. www.FormsWorkFlow.com