Free Non-County Resident Proceedings Cost Certification, F-80751 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80751 (6/08)

STATE OF WISCONSIN Bureau of Fiscal Services 608-267-3631

NON-COUNTY RESIDENT PROCEEDINGS COST CERTIFICATION
Wisconsin Statutes 51.20 (1-18), 51.40, 51.45(13), 70.60
PURPOSE: To certify and transmit from the county of proceedings to the subject's county of legal residence, costs incurred in civil commitment proceedings. The Department of Health Services coordinates the inclusion of these costs in the certification of State Special Charges.

PART 1 ­ To be completed by Clerk of Courts - Attach Supporting Documentation
COUNTY OF LEGAL RESIDENCE
There must be clear and convincing documentation to support the claim of Legal Residence. The preferred form of documentation is a letter from the county's Department of Programs or Human Services, acknowledging the subject's County of Legal Residence. Refer to Wisconsin Statute 51.40 for additional guidelines.

Subject Information Name ­ Last Initial Only Address

First

Middle City Court Date Disposition

Case Number State Zip Code

COUNTY OF PROCEEDINGS

Court Activity ­ Proceedings Under: (Check One) Involuntary Commitment ­ Alcohol & Intoxication Treatment s. 51.45 (13) Involuntary Commitment ­ Mental Health Treatment, s. 51.20 (1-15) Discharge by Habeas Corpus Proceedings, s. 51.45 (13)

Recommitment, s. 51.45 (13) (h) Re-examination, s. 51.20 (16)

Treatment Facility Mendota Mental Health Institute Taycheedah Correctional Institute VA Tomah Winnebago Mental Health Institute Wisconsin Resource Center VA Madison Sand Ridge Treatment Facility UW Hospital Other ­ Specify: ITEMIZED COST OF PROCEEDINGS ­ Reimbursable expenses include the following cost codes. A. Examining Physician C. Court and Judicial Officer B. Interpreter, Juror, Witness D. Sheriff and Staff Name and Position Code E. Other Cost ­ Requires Itemization and Justification Hours Fees Travel Total

TOTAL CLERK OF COURTS STATEMENT I confirm that this court did incur the above costs, which are not recoverable, for any other party or entity; and that clear and convincing documentation supports the cited legal residence. Clerk of Court ­ Name and County (Type or Print) SIGNATURE ­ Clerk of Court Date Signed

PART 2 ­ To be completed by County Clerk
COUNTY CLERK CERTIFICATION I certify that the amounts stated above have been paid by above charges totaling County Clerk ­ Name (Type or Print) County. I further certify that the are properly assessable against SIGNATURE ­ County Clerk Date Signed County.

DISTRIBUTION BY JULY 1 : Original, One Copy and Attachments Department of Health and Family Services Bureau of Fiscal Services ­ Special Charges P O Box 7850 Madison WI 53707-7850 Copy ­ Clerk of Courts Copy ­ County Clerk