Fill and Sign the State Form Fa 4172 DOC 1doc Print in Black Ink Enter

PRINT in INK FA-4171V, 01/09 Order To Show Cause and Affidavit to Change: Support/ Legal Custody/Physical Placemen t §§767.105, 767.451, and 767.59, W isconsin Statutes This form shall not be modified. It may be supplem ented with additional material. Page 1 of 3 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 from the original case file. For Official Use On the far right, mark the box for the change(s) you are requesting and enter the original case number. Petitioner/Joint Petitioner : First name Middle name Last name Current Mailing Address City State Zip Daytime phone number vs. 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 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. Order To Show Cause and Affidavit to Change: Legal Custody Physical Placement Child Support Maintenance Other: Case No. ORDER TO SHOW CAUSE Upon the attached Affidavit, IT IS ORDERED THAT Before Location Date Time a.m./p.m. , or as soon as the matter may be heard, to show cause (give reasons) why the requests in the attached affidavit should not be granted. If you do not appear as indicated, the court may pr oceed without you and grant the request. IT IS FURTHER ORDERED that: • a copy of this order and affidavit be personally s erved upon all other parties at least 5 business days before the date of the hearing. • both parties bring to court a fully completed, dated, and signe d Income and Expense Statement and all required attachments. BY THE COURT: For Court Use Only. Circuit Court Judge Name Printed or Typed Date For Court Use Only: This section will be completed by the court. Enter the name of the party you want to appear in court. Order To Show Cause and Affidavit to Change: Support/ Legal Custody/Physical Placement Page 2 of 3 Ca se No. _______________ FA-4171V, 01/09 Order To Show Cause and Affidavit to Change: Support/Legal Custody/Physical Placement §§767.105, 767.451, and 767.59, W isconsin Statutes This form shall not be modified. It may be supplem ented with additional material. Page 2 of 3 AFFIDAVIT 1. I am requesting that the court: A. change the existing legal custody or physical plac ement of the following children: 1. to joint legal custody with both parents. 2. to sole legal custody with me. 3. from primary physical placement with (name of parent) to (name of parent) . 4. from shared placement to primary placement with (name of parent) 5. from the current placement schedule (if any) to a new schedule I have attached. 6. to require placement be supervised. unsupervised. The other party and I: attempted mediation on (date) have not attempted mediation for this issue. B. Change the following support orders as follows: 1. Child support that is currently $ per to: a. a new amount based on state child support standard s determined by the court. b. a new set amount of $ per . c. held open as of (date) . d. Payments to be made by (name of parent) . 2. Maintenance (spousal support) that is currently $ per to: a. an amount to be determined by the court based on c urrent income. b. a new set amount of $ per . 3. Arrears payment that is currently $ per to: a. an amount to be determined by the court. b. a new set amount of $ per . 4. Arrears balance as it is currently reflected in the WI SCTF KIDS c omputer system as $ to $ because: a. I have made support or other payments directly to the other party. b. I dispute the amount that is currently on record. I will be able to provide documentation to the cour t that supports my request. C. Other change(s): See attached 2. The court order that I am asking to be modified wa s dated: . 3. This request is based on the following substantial change in circumstances that have occurred since the entry of the prior court order i n this case: A. A child who was living with the other parent is no w living with me. B. A child is no longer eligible for child support be cause the child has reached age 18, or is over 18 but under 19, and is no longer pursuing a course of education leading to a high school diploma or its equivalent. C. One of the parties has or will be moving to a diff erent residence. D. There is not a placement schedule and the parties cannot agree. E. Employment or work shift of has changed. both parties has changed . F. Income or wages of has changed. both parties has changed . G. The party to whom I owe maintenance has remarried. H. Other: If you are requesting any changes to legal custody or physical placement, check A , enter the names of the children involved, and check all that apply in 1-6. Complete all relevant information, and attach a copy of your proposed placement schedule, if applicable. Indicate if you have attempted Mediation or not, if so indicate the date of the Mediation session. If you are requesting any changes related to a support order, check B, check all that apply in 1- 4, and complete all relevant information for each section checked. Check all that apply in A-H. If E or F, enter the party’s information that has changed. If other, enter the change in circumstance that has prompted you to bring this Motion. Enter the date the current court order or judgment was signed by a court official. Order To Show Cause and Affidavit to Change: Support/ Legal Custody/Physical Placement Page 3 of 3 Ca se No. _______________ FA-4171V, 01/09 Order To Show Cause and Affidavit to Change: Support/Legal Custody/Physical Placement §§767.105, 767.451, and 767.59, W isconsin Statutes This form shall not be modified. It may be supplem ented with additional material. Page 3 of 3 4. The facts explaining the substantial change in circ umstances or deviation in child support percentage standard are: See attached If you require reasonable accommodations due to a d isability, in order to participate in the court process, please call: at least ten (10) working days prior to the schedu led court date. Please note that the court does not pr ovide transportation. STOP! Take this document to a Notary Public BEFORE you si gn 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) A copy of this Order to Show Cause and Affidavit mu st be served upon all other parties at least 5 business days before the date of the hearing. See the Service Pa cket for more information. Describe the facts that justify the change you want. Attach additional pages, if necessary.