Form Fa 4105V is a form used by the Social Security Administration to request verification of benefits. This form can be used to request information about current or past benefits, including how much was paid and when it was paid. The form can also be used to request information about any work that has been done while receiving social security disability benefits. Completed forms should be submitted to the Social Security Administration office where the claimant's case is currently pending.
| Question | Answer |
|---|---|
| Form Name | Fa 4105V Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | summons without minor children, fa 4105, fa 4108v, wslh requisition form a 4105 |
PRINT in BLACK ink |
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Enter the name of the |
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STATE OF WISCONSIN, CIRCUIT COURT, |
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For Official Use |
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county in which you are |
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COUNTY |
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filing this case. |
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In re the marriage of: |
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Enter your name (you are |
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Petitioner: |
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the petitioner). |
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First name |
Middle name |
Last name |
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Enter your address. |
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Address |
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On the far right, check |
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Address |
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divorce or legal |
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separation. |
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City |
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and |
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Summons |
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Respondent: |
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Without Minor Children |
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Enter your spouse’s name |
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(your spouse is the |
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respondent). |
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First name |
Middle name |
Last name |
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Enter your spouse’s |
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Legal |
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address. |
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Address |
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Note: Leave case number blank; the clerk will add this.
Address
City |
State |
Zip |
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Case No.
Enter the name and address of the identified government office.
DO NOT leave these lines blank. You must obtain these addresses and fill them in, or your Summons will be incomplete and will harm your case.
This information may be available in the local phone book under listings for the county or from your local Clerk of Court’s office.
The State of Wisconsin, to the person named above as respondent:
You are notified that your spouse has filed a lawsuit or other legal action against you. The Petition, which is attached, states the nature and basis of the legal action.
Within 20 days of receiving this Summons, you must provide a written response, as that term is used in ch. 802, Wis. Stats., to the Petition. The court may reject or disregard a response that does not follow the requirements of the statutes.
The response must be sent or delivered to the following government office:
Clerk of Court
Name of county
Address
Address
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State |
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Zip |
The response must also be mailed or delivered within 20 days to the petitioner at the address above.
It is recommended, but not required, that you have an attorney help or represent you.
§§767.215(2m) and 801.095, Wisconsin Statutes |
This form shall not be modified. It may be supplemented with additional material.
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Case No. _______________ |
If you do not provide a proper response within 20 days, the court may grant judgment against you, and you may lose your right to object to anything that is or may be incorrect in the Petition.
A judgment may be enforced as provided by law. A judgment may become a lien against any real estate you own now or in the future, and may also be enforced by garnishment or seizure of property.
If you need help in this matter because of a disability, please call:
Sign and print your name.
Enter the date on which you signed your name.
Note: This signature does not need to be notarized.
Signature
Name Printed or Typed
Date
§§767.215(2m) and 801.095, Wisconsin Statutes |
This form shall not be modified. It may be supplemented with additional material.
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