AB75-SSA1,1301,55 DESIGNATION OF HEALTH CARE AGENT
AB75-SSA1,1301,206 If I am no longer able to make health care decisions for myself, due to my
7incapacity, I hereby designate.... (print name, address and telephone number) to be
8my health care agent for the purpose of making health care decisions on my behalf.
9If he or she is ever unable or unwilling to do so, I hereby designate.... (print name,
10address and telephone number) to be my alternate health care agent for the purpose
11of making health care decisions on my behalf. Neither my health care agent nor my
12alternate health care agent whom I have designated is my health care provider, an
13employee of my health care provider, an employee of a health care facility in which
14I am a patient or a spouse of any of those persons, unless he or she is also my relative.
15For purposes of this document, "incapacity" exists if 2 physicians or a physician and
16a psychologist who have personally examined me sign a statement that specifically
17expresses their opinion that I have a condition that means that I am unable to receive
18and evaluate information effectively or to communicate decisions to such an extent
19that I lack the capacity to manage my health care decisions. A copy of that statement
20must be attached to this document.
AB75-SSA1,1301,2121 GENERAL STATEMENT OF AUTHORITY GRANTED
AB75-SSA1,1302,322 Unless I have specified otherwise in this document, if I ever have incapacity I
23instruct my health care provider to obtain the health care decision of my health care
24agent, if I need treatment, for all of my health care and treatment. I have discussed
25my desires thoroughly with my health care agent and believe that he or she

1understands my philosophy regarding the health care decisions I would make if I
2were able. I desire that my wishes be carried out through the authority given to my
3health care agent under this document.
AB75-SSA1,1302,124 If I am unable, due to my incapacity, to make a health care decision, my health
5care agent is instructed to make the health care decision for me, but my health care
6agent should try to discuss with me any specific proposed health care if I am able to
7communicate in any manner, including by blinking my eyes. If this communication
8cannot be made, my health care agent shall base his or her decision on any health
9care choices that I have expressed prior to the time of the decision. If I have not
10expressed a health care choice about the health care in question and communication
11cannot be made, my health care agent shall base his or her health care decision on
12what he or she believes to be in my best interest.
AB75-SSA1,1302,1313 LIMITATIONS ON MENTAL HEALTH TREATMENT
AB75-SSA1,1302,1814 My health care agent may not admit or commit me on an inpatient basis to an
15institution for mental diseases, an intermediate care facility for persons with mental
16retardation, a state treatment facility or a treatment facility. My health care agent
17may not consent to experimental mental health research or psychosurgery,
18electroconvulsive treatment or drastic mental health treatment procedures for me.
AB75-SSA1,1302,2019 ADMISSION TO NURSING HOMES OR
20 COMMUNITY-BASED RESIDENTIAL FACILITIES
AB75-SSA1,1302,2221 My health care agent may admit me to a nursing home or community-based
22residential facility for short-term stays for recuperative care or respite care.
AB75-SSA1,1302,2523 If I have checked "Yes" to the following, my health care agent may admit me for
24a purpose other than recuperative care or respite care, but if I have checked "No" to
25the following, my health care agent may not so admit me:
AB75-SSA1,1302,26
11. A nursing home — Yes.... No....
AB75-SSA1,1303,22 2. A community-based residential facility — Yes.... No....
AB75-SSA1,1303,43 If I have not checked either "Yes" or "No" immediately above, my health care
4agent may admit me only for short-term stays for recuperative care or respite care.
AB75-SSA1,1303,55 PROVISION OF A FEEDING TUBE
AB75-SSA1,1303,106 If I have checked "Yes" to the following, my health care agent may have a
7feeding tube withheld or withdrawn from me, unless my physician has advised that,
8in his or her professional judgment, this will cause me pain or will reduce my comfort.
9If I have checked "No" to the following, my health care agent may not have a feeding
10tube withheld or withdrawn from me.
AB75-SSA1,1303,1311 My health care agent may not have orally ingested nutrition or hydration
12withheld or withdrawn from me unless provision of the nutrition or hydration is
13medically contraindicated.
AB75-SSA1,1303,1414 Withhold or withdraw a feeding tube — Yes.... No....
AB75-SSA1,1303,1615 If I have not checked either "Yes" or "No" immediately above, my health care
16agent may not have a feeding tube withdrawn from me.
AB75-SSA1,1303,1817 HEALTH CARE DECISIONS FOR
18 PREGNANT WOMEN
AB75-SSA1,1303,2219 If I have checked "Yes" to the following, my health care agent may make health
20care decisions for me even if my agent knows I am pregnant. If I have checked "No"
21to the following, my health care agent may not make health care decisions for me if
22my health care agent knows I am pregnant.
AB75-SSA1,1303,2323 Health care decision if I am pregnant — Yes.... No....
AB75-SSA1,1304,3
1If I have not checked either "Yes" or "No" immediately above, my health care
2agent may not make health care decisions for me if my health care agent knows I am
3pregnant.
AB75-SSA1,1304,54 STATEMENT OF DESIRES,
5 SPECIAL PROVISIONS OR LIMITATIONS
AB75-SSA1,1304,96 In exercising authority under this document, my health care agent shall act
7consistently with my following stated desires, if any, and is subject to any special
8provisions or limitations that I specify. The following are specific desires, provisions
9or limitations that I wish to state (add more items if needed):
AB75-SSA1,1304,1513 INSPECTION AND DISCLOSURE OF
14 INFORMATION RELATING TO MY PHYSICAL
15 OR MENTAL HEALTH
AB75-SSA1,1304,1716 Subject to any limitations in this document, my health care agent has the
17authority to do all of the following:
AB75-SSA1,1304,1918 (a) Request, review and receive any information, oral or written, regarding my
19physical or mental health, including medical and hospital records.
AB75-SSA1,1304,2120 (b) Execute on my behalf any documents that may be required in order to obtain
21this information.
AB75-SSA1,1304,2222 (c) Consent to the disclosure of this information.
AB75-SSA1,1304,2323 (The principal and the witnesses all must sign the document at the same time.)
AB75-SSA1,1304,2424 SIGNATURE OF PRINCIPAL
AB75-SSA1,1304,2525 (person creating the power of attorney for health care)
AB75-SSA1,1304,26
1Signature....  Date....
AB75-SSA1,1305,32 (The signing of this document by the principal revokes all previous powers of
3attorney for health care documents.)
AB75-SSA1,1305,44 STATEMENT OF WITNESSES
AB75-SSA1,1305,155 I know the principal personally and I believe him or her to be of sound mind and
6at least 18 years of age. I believe that his or her execution of this power of attorney
7for health care is voluntary. I am at least 18 years of age, am not related to the
8principal by blood, marriage, or adoption, am not the domestic partner under ch. 770
9of the principal,
and am not directly financially responsible for the principal's health
10care. I am not a health care provider who is serving the principal at this time, an
11employee of the health care provider, other than a chaplain or a social worker, or an
12employee, other than a chaplain or a social worker, of an inpatient health care facility
13in which the declarant is a patient. I am not the principal's health care agent. To
14the best of my knowledge, I am not entitled to and do not have a claim on the
15principal's estate.
AB75-SSA1,1305,1616 Witness No. 1:
AB75-SSA1,1305,1717 (print) Name.... Date....
AB75-SSA1,1305,1818 Address....
AB75-SSA1,1305,1919 Signature....
AB75-SSA1,1305,2020 Witness No. 2:
AB75-SSA1,1305,2121 (print) Name.... Date....
AB75-SSA1,1305,2222 Address....
AB75-SSA1,1305,2323 Signature....
AB75-SSA1,1305,2524 STATEMENT OF HEALTH CARE AGENT AND
25 ALTERNATE HEALTH CARE AGENT
AB75-SSA1,1306,4
1I understand that.... (name of principal) has designated me to be his or her
2health care agent or alternate health care agent if he or she is ever found to have
3incapacity and unable to make health care decisions himself or herself. .... (name of
4principal) has discussed his or her desires regarding health care decisions with me.
AB75-SSA1,1306,55 Agent's signature....
AB75-SSA1,1306,66 Address....
AB75-SSA1,1306,77 Alternate's signature....
AB75-SSA1,1306,88 Address....
AB75-SSA1,1306,119 Failure to execute a power of attorney for health care document under chapter
10155 of the Wisconsin Statutes creates no presumption about the intent of any
11individual with regard to his or her health care decisions.
AB75-SSA1,1306,1312 This power of attorney for health care is executed as provided in chapter 155
13of the Wisconsin Statutes.
AB75-SSA1,1306,1414 ANATOMICAL GIFTS (optional)
AB75-SSA1,1306,1515 Upon my death:
AB75-SSA1,1306,1716 .... I wish to donate only the following organs or parts: .... (specify the organs or
17parts).
AB75-SSA1,1306,1818 .... I wish to donate any needed organ or part.
AB75-SSA1,1306,1919 .... I wish to donate my body for anatomical study if needed.
AB75-SSA1,1306,2220 .... I refuse to make an anatomical gift. (If this revokes a prior commitment that
21I have made to make an anatomical gift to a designated donee, I will attempt to notify
22the donee to which or to whom I agreed to donate.)
AB75-SSA1,1306,2423 Failing to check any of the lines immediately above creates no presumption
24about my desire to make or refuse to make an anatomical gift.
AB75-SSA1,1306,2525 Signature....     Date....
AB75-SSA1, s. 2441
1Section 2441. 155.40 (2) of the statutes is amended to read:
AB75-SSA1,1307,62 155.40 (2) If the health care agent is the principal's spouse or domestic partner
3under ch. 770
and, subsequent to the execution of a power of attorney for health care
4instrument, the marriage is annulled or divorce from the spouse is obtained or the
5domestic partnership under ch. 770 is terminated
, the power of attorney for health
6care is revoked and the power of attorney for health care instrument is invalid.
AB75-SSA1, s. 2442 7Section 2442. 157.05 of the statutes is amended to read:
AB75-SSA1,1307,14 8157.05 Autopsy. Consent for a licensed physician to conduct an autopsy on
9the body of a deceased person shall be deemed sufficient when given by whichever
10one of the following assumes custody of the body for purposes of burial: Father,
11mother, husband, wife, child, guardian, next of kin, domestic partner under ch. 770,
12or in the absence of any of the foregoing, a friend, or a person charged by law with
13the responsibility for burial. If 2 or more such persons assume custody of the body,
14the consent of one of them shall be deemed sufficient.
AB75-SSA1, s. 2443 15Section 2443. 157.06 (9) (a) 2. of the statutes is amended to read:
AB75-SSA1,1307,1616 157.06 (9) (a) 2. The spouse or domestic partner under ch. 770 of the individual.
AB75-SSA1, s. 2443m 17Section 2443m. 165.03 of the statutes is created to read:
AB75-SSA1,1307,22 18165.03 Funding for assistant district attorney and public defender
19retention pay.
(1) Notwithstanding the purposes for which appropriations are
20made under s. 20.455, in each fiscal year, the attorney general shall transfer to the
21appropriation account under s. 20.455 (3) (kb) a total of $1,000,000 from
22appropriation accounts under s. 20.455 except all of the following:
AB75-SSA1,1307,2323 (a) A sum sufficient appropriation.
AB75-SSA1,1307,2424 (b) An appropriation of federal moneys.
AB75-SSA1,1308,2
1(c) An appropriation from which transfer of moneys under this subsection is
2prohibited under the constitution.
AB75-SSA1,1308,3 3(2) (a) In this subsection:
AB75-SSA1,1308,54 1. "District attorney percentage" means the percentage of total assistant
5attorney positions that are assistant district attorney positions.
AB75-SSA1,1308,76 2. "Public defender percentage" means the percentage of total assistant
7attorney positions that are assistant state public defender positions.
AB75-SSA1,1308,108 3. "Total assistant attorney positions" means the total full-time equivalent
9assistant district attorney positions filled as of June 30th of a fiscal year plus the total
10full-time equivalent assistant state public defender positions filled on that date.
AB75-SSA1,1308,1411 (b) On June 30th of each fiscal year, the attorney general shall transfer from
12the appropriation account under s. 20.455 (3) (kb) to the appropriation account under
13s. 20.475 (1) (kb) an amount equal to $1,000,000 multiplied by the district attorney
14percentage.
AB75-SSA1,1308,1815 (c) On June 30th of each state fiscal year, the attorney general shall transfer
16from the appropriation account under s. 20.455 (3) (kb) to the appropriation account
17under s. 20.550 (1) (kb) an amount equal to $1,000,000 multiplied by the public
18defender percentage.
AB75-SSA1, s. 2444b 19Section 2444b. 165.25 (4) (ar) of the statutes, as affected by 2009 Wisconsin
20Act 2
, is amended to read:
AB75-SSA1,1309,221 165.25 (4) (ar) The department of justice shall furnish all legal services
22required by the department of agriculture, trade and consumer protection relating
23to the enforcement of ss. 91.68, 93.73, 100.171, 100.173, 100.174, 100.175, 100.177,
24100.18, 100.182, 100.195, 100.20, 100.205, 100.207, 100.209, 100.21, 100.28, 100.37,

1100.42, 100.50, 100.51, 100.55, and 846.45 and chs. 126, 136, 344, 704, 707, and 779,
2together with any other services as are necessarily connected to the legal services.
AB75-SSA1, s. 2446 3Section 2446. 165.755 (1) (a) of the statutes is amended to read:
AB75-SSA1,1309,74 165.755 (1) (a) Except as provided in par. (b), a court shall impose under ch. 814
5a crime laboratories and drug law enforcement surcharge of $8 $13 if the court
6imposes a sentence, places a person on probation, or imposes a forfeiture for a
7violation of state law or for a violation of a municipal or county ordinance.
AB75-SSA1, s. 2447m 8Section 2447m. 165.785 of the statutes is created to read:
AB75-SSA1,1309,13 9165.785 Crime alert network. (1) In addition to its duties under ss. 165.50
10and 165.78, the department may develop, administer, and maintain an integrated
11crime alert network to provide information regarding known or suspected criminal
12activity, crime prevention, and missing or endangered children or adults to state
13agencies, law enforcement officers, and members of the private sector.
AB75-SSA1,1309,15 14(2) The department may charge a fee to members of the private sector who
15receive information under sub. (1).
AB75-SSA1, s. 2448 16Section 2448. 165.82 (1) (a) and (ag) of the statutes are consolidated,
17renumbered 165.82 (1) (a) and amended to read:
AB75-SSA1,1309,2018 165.82 (1) (a) For each record check, except a fingerprint card record check,
19requested by a nonprofit organization, $2. (ag) For each record check, except a
20fingerprint card record check, requested
or by a governmental agency, $5 $7.
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