Fill and Sign the Fa 4139 Financial Disclosure Statement Law Form

PRINT in BLACK ink FA-4123 Pro Se, 01/06 Publication Affidavit of Mailing §801.10, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 Enter the name of the county in which this case is filed. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Enter your name. For Official Use On the far right, check divorce or legal separation. In re the marriage of: Petitioner: First name Middle name Last name and Enter your spouse’s name. Enter the case number. Respondent: First name Middle name Last name Publication Affidavit of Mailing Divorce-40101 Legal Separation-40201 Case No. Under oath I state that 1. The respondent is being served the authenticated Summons and Petition by publication. A separate affidavit of publication from the publisher/printer will be filed with the court. 2. In order to comply with statutory requirements for publication, I have also placed in an envelope a copy of the authenticated Summons and Petition. 3. I mailed that envelope with proper postage affixed on (date) to: Name Address Address City State Zip STOP! Take this document to a Notary Public BEFORE you sign it. After you have been sworn by a Notary Public, sign and print your name and date the document in front of the Notary Public. Signature Print or Type Name Date Have the Notary Public sign, date, and seal the document. Subscribed and sworn to before me on Notary Public, State of W isconsin My commission expires: (Seal) Enter the date [month, day, year] on which you placed the documents in a mailbox, and the name and last known address of the respondent.