Fill and Sign the Respondentjoint Petitioner B Wisconsin Supreme Court Form

Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-4175V, 05/17 Decision &and Order on Motion or Order to Sho w Cause to Change: Legal Custody/ §§767.451 and 767.59, W isconsin Statutes Physical Custody/Child Support/Maintena nce/Arrears Payment/Other This form shall not be modified. It may be supplemented with additional material. Page 1 of 5 Enter the name of the county in which the original case was filed. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Check 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 A from the original case file. Petitioner/Joint Petitioner A Name (First, Middle and Last) Current Mailing Address City State Zip Daytime phone number - vs - On the far right, mark the box for the change(s) you requested and enter the original case number. Decision and Order on Motion or Order T o Show Cause to Change Legal Custody Physical Placement Child Support Maintenance Arrears Payment Other: Case No. Enter the name, address, and daytime phone number of the respondent or joint petitioner B from the original case file. Respondent/Joint Petitioner B Name (First, Middle and Last) Current Mailing Address City State Zip Daytime phone number Check 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. STOP! Do not complete the remainder of this form unless required by the court official who is hearing this case. HEARING Enter the name of the court official who held the hearing and the address and date [month, day, year] on which it was held. A hearing was conducted in this matter as follows: 1. Before Circuit Court Judge/Circuit Court Commissioner 2. Location 3. Date Time a.m. p.m. APPEARANCES Check one box from 1 and check A or B. If B, enter the name of the attorney. 1. Former Petitioner/Joint Petitioner A appeared in person appeared by phone did not appear AND A. was self-represented. B. was represented by Attorney . Check one box from 2 and check A or B. If B, enter the name of the attorney. 2. Former Respondent/Joint Petitioner B appeared in person appeared by phone did not appear AND A. was self-represented. B. was represented by Attorney . Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: Decision and Order on Motion or Order to Show Cause to Cha nge Page 2 of 5 Case No. ____________ FA-4175V , 05/17 Decision and Order on Motion or Order to Show Cause to Chang e: Legal Custody/ §§767.451 and 767.59, W isconsin Statutes Physical Custody/Child Support/Maintena nce/Arrears Payment/Other This form shall not be modified, It may be supplemented with additional mat erial. Page 2 of 5 In 3, check A, B, C, or D. If B, C, or D, enter the name of the individual who appeared. 3. Others appearing at the hearing: A. None. B. Child Support Agency by . C. Guardian ad Litem (GAL) . D. Other: . FINDINGS and ORDER Based on the findings and reasons stated, IT IS ORDERED: In 1, check A, B, or C. Check A if the court denied the request to change the order. 1. The Motion or Order to Show Cause is A. DENIED because no substantial change in circumstance was found. The current order remains in effect. Check B if the judge ordered the parties to do certain things before he/she makes a decision. If B, check all that apply and complete the corresponding information as necessary. B. DEFERRED to collect more information. Before making a final decision the cour t orders the following: 1) The parties attend mediation with a. no payment is required. b. Petitioner/Joint Petitioner A to pay $ towards the mediation fee by . c. Respondent/Joint Petitioner B to pay $ towards the mediation fee by . 2) Attorney be appointed as GAL and a. no payment is required. b. Petitioner/Joint Petitioner A pay $ towards the GAL fee by . c. Respondent/Joint Petitioner B to pay $ towards the GAL fee by . 3) A physical placement study be conducted by . a. no payment is required. b. Petitioner/Joint Petitioner A to pay $ towards the study fee by . c. Respondent/Joint Petitioner B to pay $ towards the study fee by . 4) Other: Check C, if the judge ordered changes to the current court order. If 1, enter the children’s names and check all that apply in a-f, and complete the corresponding information as was ordered by the court. C. GRANTED as follows: 1) Physical Placement Order(s) (time with children) for the following minor children: a. from primary physical placement with [Name of Parent] to primary placement with (Name of Parent) b. from shared placement to primary placement with [Name of Parent] c. from primary placement to shared placement. d. from the current shared placement schedule (if any) to a new shared placement schedule. The new placement schedule for the changes in a-d above is as follows: See attached e. to require placement with [Name of Parent] be supervised. unsupervised. f. Other: See attached Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: Decision and Order on Motion or Order to Show Cause to Cha nge Page 3 of 5 Case No. ____________ FA-4175V , 05/17 Decision and Order on Motion or Order to Show Cause to Chang e: Legal Custody/ §§767.451 and 767.59, W isconsin Statutes Physical Custody/Child Support/Maintena nce/Arrears Payment/Other This form shall not be modified, It may be supplemented with additional mat erial. Page 3 of 5 If 2, enter the children’s names and check all that apply in a- c. 2) Legal Custody (decision making) for the following children: a. to joint legal custody with both parents. b. to sole legal custody with [Name of Parent] c. Other: See attached 3) Medical Insurance and Payments . Parents are required to provide private health insurance for their minor child(ren) if service providers are located within 30 miles or 30 minutes from the child’s residence and if the cost is reasonable. Reasonable cost is defined as the difference between single and family coverage where the added cost does not exceed 5% of the insuring parent’s monthly income available for child support. The insuring parent may receive a contribution toward the cost of the insurance from the other parent, either as a credit against the child support obligation or an increase in the non- insuring parent’s child support obligation as long as the increase does not exceed 5% of the non -insuring parent’s gross monthly income. The parties understand that such medical insurance coverage for the minor child(ren) including medical, dental, orthodontic, hospital, psychiatric, counseling, drug and other health expenses which is currently offered shall be provided and paid by Check a, b, c, or d . a. both parties. They shall provide private health insurance and neither parent is required to make a cash contribution to the other. If b, enter who will provide insurance, the out of pocket cost for such insurance, and the amount the other party will contribute. b. shall provide private health insurance. The out of pocket cost (difference between single and family coverage) to cover the child(ren) under such insurance is $ . The other parent shall contribute $ toward that cost (as a reasonable cash contribution) and that amount, if any, is inc luded as a deviation in the child support calculation in 4.b . of Child Support and Financial Expenses below. If c, indicate who will be responsible for providing public health insurance and whether the children are enrolled or need to need to be enrolled. c. A comprehensive private health insurance policy is not available to either parent at a reasonable cost. The Petitioner/Joint Petitioner A Respondent/Joint Petitioner B has enrolled in shall promptly apply for Public Health Insurance. 1. There is no out of pocket expense for the above Public Health Insurance. Also, check 1 or 2. If 2, indicate the cost for such insurance and the amount the other party will contribute, 2. Out of pocket cost for such insurance is $ . The other parent shall contribute $ toward that cost (as a reasonable cash contribution) and that amount, if any, is included as a deviation in the child support calculation in 4.b. of Child Support and Financial Expenses below. If accessible private health insurance becomes available at a reasonable cost to either parent, that parent shall enroll the child(ren) as covered dependents under his/her health insurance. If d, check which party has income below 150% of the fe deral poverty level. d. Petitioner/Joint Petitioner A Respondent/Joint Petitioner B does not have free health insurance available and has income below 150% of the federal poverty level and is therefore unable to make a cash contribution toward the cost of the child(ren)’s healthcare. The appropriate cash medical support obligation is $0. If accessible private health insurance becomes available at a reasonable cost to either parent, that parent shall enroll the child(ren) as covered dependents under his/her health insurance. The insuring parent shall provide the other parent and the child support agency with copies of policy information and insurance cards. The insuring parent shall inform the child support agency about any change in his/her employment and the availability of insurance. Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: Decision and Order on Motion or Order to Show Cause to Cha nge Page 4 of 5 Case No. ____________ FA-4175V , 05/17 Decision and Order on Motion or Order to Show Cause to Chang e: Legal Custody/ §§767.451 and 767.59, W isconsin Statutes Physical Custody/Child Support/Maintena nce/Arrears Payment/Other This form shall not be modified, It may be supplemented with additional mat erial. Page 4 of 5 Check 4 if changing financial orders. Check a if changing child support and check the guideline that applies to the specifics of this case after considering the gross income of the parties, other payment obligations of the parties, and physica l placement of the children. 4) Change the financial orders as follows: a. Child Support to the following new amount that is based on gross income and the child support percentage of income standards. The standard calculation that applies to this case is 17% for one child. split-placement formula. 25% for two children. shared-placement formula. 29% for three children. serial-family parent formula. 31% for four children. low-income payer formula. 34% for five or more children. high-income payer formula. b. Child Support Order and Basis for a ny Deviation In b1, enter the payer’s name, recipient’s name, payment frequency (weekly, bi-weekly, monthly, bi-monthly) and guideline amount. In b.2.A., enter the medical deviation from above 1.C.3.b or c. Enter “0 ” if none. Check if this amount increases or decreases this child support. In b.2.B, enter the other deviations or “0 ” if none. In C, enter the date payments begin and determine the net child support amount after adding or subtracting the deviations from the amount in 2A. 1. Based on the above standard calculation, amount payable by to per in the amount of $ 2. The court orders a deviation from that amount of child support. A. A medical cash contribution from above in 1.C.3.b. or 1.C.3.c.2. above increases decreases this child support amount by (If no deviation, enter “0” or “None”) $ B. A deviation is based on: (Explain the reasons for any other deviation here) and this increases decreases this child support amount by (If no deviation, enter “0” or “None”) $ C. Beginning [Date] , the amount payable to per is (If no child support is to be paid, enter “0” or “Held Ope n”) $ In c-g, if applicable, enter how the court ordered the payments to be made. c . Maintenance to $ per beginning , 20 . d. Arrears payment to $ per beginning , 20 . e. Arrears balance is set in the WI SCTF KIDS computer system at $ as of , 20 . f. Arrears Interest balance is set in the WI SCTF KIDS computer system at $ as of , 20 . g. Payments shall be made 1. no payments are ordered. 2. beginning on , 20 to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee, Wisconsin 53274-0200 a. directly from the payer to WI SCTF (only allowable if self-employed ). b. by income assignment from the payer’s employer indicated below: Employer name Address of payroll office City St ate Zip Phone Fax In h, enter any other financial orders. h. Other financial order(s): See attached In 5, enter any non- financial orders. 5) Other non -financial order(s): See attached Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: Decision and Order on Motion or Order to Show Cause to Cha nge Page 5 of 5 Case No. ____________ FA-4175V , 05/17 Decision and Order on Motion or Order to Show Cause to Chang e: Legal Custody/ §§767.451 and 767.59, W isconsin Statutes Physical Custody/Child Support/Maintena nce/Arrears Payment/Other This form shall not be modified, It may be supplemented with additional mat erial. Page 5 of 5 In 6, check a or b. If b , enter the date and time of the review hearing, the judge who will preside, and the room number where the hearing will take place. 6) A future hearing a. is NOT required. b. is set for [Date] Time am. pm. before , 20 in Room # . 7) Both parties shall notify the Clerk of Courts and the local Child Support Agency in writing, within 10 business days of any change of address, employment, and of any substantial change in income affecting the ability to pay support. This notification does not change the support order. Any party may file moving papers to change this order. 8) If this matter was heard by a Court Commissioner, and either party requests a new hearing, a Request for New (DeNovo) Hearing must be filed with the Clerk of Courts within the time period established by local court rule. FAILURE TO OBEY THIS ORDER IS PUNISHABLE AS CONTEMPT OF COURT AND MAY RESULT IN A JAIL SENTENCE. THIS IS A FINAL ORDER FOR PURPOSES OF APPEAL IF SIGNED BY A CIRCUIT COURT JUDGE. BY THE COURT: For Court Use Only. Circuit Court Judge/Circuit Court Commissioner Title (Print or Type Name if not eSigned) Date When you submit this order to the court, you must send copies to the other party(s). Th e other party(s) has up to 5 business days to object to the accuracy of this order.