FORM SUMMARY Name of Form: Special Administration - Petition Form Number: PR-1850 Statutory Reference: §§867.07, 867.09, 879.57, Wisconsin Statutes Benchbook Reference: PR 8-10 Purpose of Form: To grant a special administrator the same powers, duties and liabilities as a personal representative, or only those powers and duties needed to conduct a specific purpose. Who Completes It: Any person petitions for administration of an estate. Distribution of Form: Original to court; copies to persons interested. Accompanying Forms: Order Setting Time to Hear Petition, Order Appointing Special Administrator and Letters of Special Administration. New Form/Modification: Modification; last update 10/00. Modifications: Changed Department of Health and Family Services to Department of Children and Families. Also changed “Family Care Services” to “Family Care and/or Partnership benefits”. Added “Medicaid” after “Medical Assistance” (per Kathleen Emmerton, Estate Recovery) Comments: None. About this Form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 04/24/2008 Page 1 American LegalNet, Inc. www.FormsWorkflow.com For Official Use COUNTY STATE OF WISCONSIN, CIRCUIT COURT, IN THE MATTER OF THE ESTATE OF Special Administration Petition Case No. UNDER OATH, I STATE THAT: 1. The decedent, whose date of birth was died domiciled in address of: 2. I am interested as did did was , with a post office . . (Relationship to Decedent) 3. The decedent: did not did did not did did not did not was not , , and date of death was County, State of receive Medical Assistance/Medicaid. receive Family Care and/or Partnership benefits (through a Managed Care Organization – MCO/CMO). receive benefits from the Community Options Program (COP). receive benefits from Wisconsin Chronic Disease Program. 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: 4. If more than one spouse, see attached. If the decedent was ever married, complete the following: . deceased): Name of spouse ( living or Divorced from decedent at time of decedent’s death. Married to decedent did not receive benefits from the Community Options Program (COP). did The spouse did not receive benefits from the Wisconsin Chronic Disease Program. did The spouse 5. It is necessary to appoint a special administrator because: , post office , I ask that letters of special administration be issued to: address with all the general powers, duties and liabilities as personal representative except: with only these specific powers: Subscribed and sworn to before me Signature of Petitioner on Notary Public/Court Official My commission expires: Name Printed or Typed Address Name of Attorney Address Telephone Number Telephone Number Bar Number PR-1850, 04/08 Special Administration - Petition §§867.07, 867.09, and 879.57, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. www.FormsWorkflow.com