Fill and Sign the Order Child Placement Form

PRINT in BLACK ink Enter the name of the county in which the original case was filed. STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use Mark marriage or paternity. If paternity, enter initials of child. In re the Marriage Paternity of       _____________ Enter the name, address, and daytime phone number of the petitioner or joint petitioner from the original case file. Petitioner/Joint Petitioner :       First name Middle name Last name       Current Mailing Address                         City State Zip Daytime phone number Vs.On the far right, mark the box for the change(s) you are requesting and enter the original case number. Stipulation and Order to: Change Legal Custody Change Physical Placement Change Child Support Change Maintenance Change Family Support Change Arrears Balances Other:______________________ Case No.       Enter the name, address, and daytime phone number of the respondent or joint petitioner from the original case file. Respondent/Joint Petitioner :       First name Middle name Last name       Current Mailing Address                         City State Zip Daytime phone number Mark if the State of Wisconsin is a party or not. If you are unsure, you may call your local Child Support Agency. The State of Wisconsin (Child Support Agency) is is not a party to this action. The parties agree that the judgment in this case should be changed as follows, and that the court may enter this stipulation as an order without a court hearing. 1. Modify Current Financial Order(s) A. The current financial order is as follows: 1.       pays support to       for a. Child Support in the amount of $       %       per month. b. Maintenance in the amount of $       %       per month. c. Family Support in the amount of $       %       per month. d. Arrears in the amount of $       %       per month. e. Arrears Interest in the amount of $       %       per month. f. Other Financial Orders:       2. No support is currently ordered. B. Financial Order Changes: The parties agree that support orders shall be changed as follows: 1.       shall make payments to       beginning the first day of the month of       , 20       for a. Child Support in the amount of $       per month. b. Maintenance in the amount of $       per month. c. Family Support in the amount of $       per month. d. Arrears Payment in the amount of $       per month. e. Arrears Interest in the amount of $       per month. f. Other Financial Orders:       FA-604, 10/06 Stipulation and Order to Amend Judgment for Support/Maintenance/ Custody/Placement §§767.553, 767.59, 767.451, 767.461 and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3If you are modifying financial orders, check 1 and complete A-D. In A, check 1 or 2. If 1, enter the names of the payer and payee and indicate what is currently ordered by marking all that apply in a-f and entering the amount of the current order. In B, check 1 or 2 to indicate to what amount you want the order changed. If 1, enter the names of the payer and payee, the date the order shall be effective, check all that apply in a-f, and enter the new amount. If 2, enter the reasons. 2. No support shall be ordered from either party at this time because       C. Child Support Calculation: The new order for child support is based on 1. No change in child support was made. 2. DWD Chapter 40 Child Support Percentage of Income Standard. (Based on Gross Income – 17% for one child, 25% for two children, 29% for three children, 31% for four children, 34% for five or more children) 3. This amount deviates from the DWD 40 Child Support Standard amount which would be unfair because child support should be calculated using the: a. split-placement calculation b. shared-placement calculation c. serial-family payer calculation d. low-income payer calculation e. high-income payer calculation f. other       D. Payments 1. No payments are ordered to be made. 2. Shall be made to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee, Wisconsin 53274-0200. Payments shall be made: a. Directly from the payer to WI SCTF ( only allowable if self-employed ). b . By income assignment from the payer’s employer as indicated below: Employer name:       Address of payroll office:       City:       State:       Zip:       Phone:       Fax:       3. Payments shall be made directly from one party to the other (not allowable for child support, family support, or maintenance) . 2. Modify Legal Custody Order(s): The legal custody of the following children :       is changed as follows: A. To joint legal custody with both parents. B. To sole legal custody with [name of parent]       C. Other:       3. Modify Physical Placement Order(s): The physical placement of the following children :       ____________ is changed as follows: A. To shared physical placement according to the following schedule:       See attached B. To primary physical placement with (name of parent)       ____________ and (name of parent)       ___________ _ receiving periods of physical placement (visitation) according to the following schedule:       See attached . C. To require placement be supervised unsupervised as follows ):       FA-604, 10/06 Stipulation and Order to Amend Judgment for Support/Maintenance/ Custody/Placement §§767.553, 767.59, 767.451, 767.461 and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 5If you are modifying Legal Custody, check 2, enter the names of the children, and check & complete A, B, or C.In C, check 1, 2, or 3. If 2, check the box for the percentage standard used. If 3, check which applies in a-f. If you are modifying Physical Placement, check 3, enter the names of the children, check & complete A, B, C, D, or E and enter the new orders.In D, check 1, 2, or 3. If 2, check a or b. If b, complete the payer’s employer information. See attached . D. According to the attached placement schedule. E. Other:       See attached . FA-604, 10/06 Stipulation and Order to Amend Judgment for Support/Maintenance/ Custody/Placement §§767.553, 767.59, 767.451, 767.461 and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 5 4. Additional Changes are as follows:       See attached . The former wife/mother must sign and print her name. Enter the date on which she signed her name. Note: This signature does not need to be notarized. Signature       Print or Type Name       Date The former husband/father must sign and print his name. Enter the date on which he signed his name. Note: This signature does not need to be notarized. Signature       Print or Type Name       Date State of Wisconsin, Child Support Agency If either party is receiving public assistance or there is a case worker from the Child Support Agency assigned to your case, you must take this agreement to the Child Support Agency in your county for their approval. If not, mark not required. Approved Not Approved Not Required Authorized Signature       Print or Type Name       Date THE COURT ORDERS: 1. This stipulation is approved and the judgment is amended accordingly. 2. All provisions of the previous judgment not amended by this order remain in full effect. BY THE COURT: FA-604, 10/06 Stipulation and Order to Amend Judgment for Support/Maintenance/ Custody/Placement §§767.553, 767.59, 767.451, 767.461 and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 5If you are modifying anything else, check and complete 4. For Court Use Only _____________________________________________ Circuit Court Judge/Court Commissioner       ________________________________________ Print or Type Name       ________________________________________ Date FA-604, 10/06 Stipulation and Order to Amend Judgment for Support/Maintenance/ Custody/Placement §§767.553, 767.59, 767.451, 767.461 and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 5 of 5