Fill and Sign the Provide Statement Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE INTEREST OF       Name Order to Provide Statement of Income, Assets, Debts and Living Expenses       Date of Birth Case No.       It appears to the court that this case may include placement outside the home. IT IS ORDERED: The parent(s) shall complete the attached statement of income, assets, debts and living expenses, and shall provide the original statement to the juvenile court clerk: at least five days before the date set for the dispositional hearing. by       . A copy shall also be provided to the agency primarily responsible for implementing the dispositional order:       The parent(s) are further informed that information concerning the percentage standards and the factors the court may consider in establishing the level of support is either attached or on the reverse side. BY THE COURT: Signature of Circuit Court Judge/Court Commissioner       Name Printed or Typed       Date JD-1717 , 05/00 Order to Provide Statement of Income, Assets, Debts and Living Expenses Chapters 48 and 938, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Order to Provide Statement of Income, Assets, Debts and Living Expenses Page 2 of 2 Case No. The parents are informed that the court may order a child support payment for children placed outside the home. The percentage standards established by the Department of Workforce Development: One child 17% of gross income Two children 25% of gross income Three children 29% of gross income Four children 31% of gross income Five children 34% of gross income The factors that the court may consider in determining the level of support are:  The needs of the child.  The physical, mental and emotional health needs of the child, including any costs for the child's health insurance provided by a parent.  The standard of living and circumstances of the parents, including the needs of each parent to support himself or herself at a level equal to or greater than that established under 42 USC 9902(2) (poverty guidelines).  The financial resources of the parent.  The earning capacity of each parent, based on each parent’s education, training and work experience and based on the availability of work in or near the parent’s community.  The need and capacity of the child for education, including higher education.  The age of the child.  The financial resources and the earning ability of the child.  The needs of any person, including dependent children other than the child, whom either parent is legally obligated to support.  The best interests of the child, including, but not limited to, the impact on the child of expenditures by the family for improvement of any conditions in the home that would facilitate the reunification of the child with the child's family, if appropriate, and the importance of a placement that is the least restrictive of the rights of the child and the parents and the most appropriate for meeting the needs of the child and the family.  Any other factors that the court in each case determines are relevant. JD-1717 , 05/00 Order to Provide Statement of Income, Assets, Debts and Living Expenses Chapters 48 and 938, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2