PR-1850, 11/12 Petition for Special Administration (Formal Administration) 247247867.07 and 867.09, 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 ESTATE OF Name Amended Petition for Special Administration (Formal Administration) Case No. UNDER OATH, I STATE: 1. The decedent, with date of birth and date of death , was domiciled in County, State of , with a mailing address of . 2. I am interested as . 3. Other proceedings concerning the estate of the decedent are not pending are currently pending were previously completed in Wisconsin or elsewhere. Explain: 4. The decedent did did not receive Medical Assistance/Medicaid. did did not receive Family Care and/or Partnership benefits (through a Managed Care Organization MCO/CMO). did did not receive benefits from the Community Options Program (COP). did did not receive benefits from Wisconsin Chronic Disease Program. was was not a patient or inmate of a state or county hospital or institution, or responsible for any person owing an obligation to the state or county. Explain: The petitioner lacks information to complete this section. 5. If the decedent was ever married, complete the following: (If more than one spouse, See attached.) Name of spouse: [ living or deceased] . Married to decedent. Divorced from decedent. The spouse did did not receive benefits from the Community Options Program (COP). The spouse did did not receive benefits from the Wisconsin Chronic Disease Program. The petitioner lacks information to complete this section. 6. The decedent died leaving a will, dated . codicil(s) (if any), dated . 7. The names and mailing addresses of all interested persons are: (For any person with disabilities, also list any guardian of estate; for any person in the military, also list attorney or attorney in fact; and for any minor, list date of birth.) Name Relationship Mailing Address If Minor, Date of Birth American LegalNet, Inc. www.FormsWorkFlow.com PR-1850, 11/12 Petition for Special Administration (Formal Administration) 247247867.07 and 867.09, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 8. It is necessary to appoint a special administrator because A. there is no estate to be administered and an act should be performed on the part of the decedent, the performance of which affects or is of importance to the petitioner or any other person. B. the final judgment of distribution in the estate has been entered and an act remains unperformed in the estate, or unadministered assets have been found or may be found belonging to the estate. C. the estate can be settled under summary settlement or summary assignment. D. it is necessary to conserve or administer the estate of a decedent before letters can be issued to a personal representative. E. circumstances provided in 247867.05(5)&(6), Wis. Stats., exist. F. a cause of action exists for or against the decedent or the decedent's estate and it is necessary that some act be performed before letters can be issued to a personal representative. G. other circumstances exist which in the discretion of the court require the appointment of a special administrator. H. Other: 9. The special administrator requires A. only these specific powers: B. all the general powers, duties and liabilities as personal representative. Except: 10. Other: I REQUEST THE COURT: 1. Set a hearing on the Petition. 2. Order notice, if required by the court. 3. Grant the Petition authorizing powers, duties and liabilities of special administrator as stated above. 4. Issue Letters of Special Administration to , mailing address . 5. Other: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Address Telephone Number Form completed by: (Name) Address Telephone Number Bar Number American LegalNet, Inc. www.FormsWorkFlow.com