Fa 4126V Form – Fill Out and Use This PDF

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Enter the name of the		STATE OF WISCONSIN, CIRCUIT COURT,
county in which you are					COUNTY
filing this case.
Enter the name of the		In RE: The marriage of
petitioner. If joint		Petitioner/Joint Petitioner-Wife:
petitioners, enter the name
of the wife.
		First name	Middle name	Last name

FOR OFFICIAL USE

Enter the name of the respondent. If joint petitioners, enter the name of the husband.

Check divorce or legal separation.

NOTE: Enter the case number, if known. If not leave blank.

and

Respondent/Joint Petitioner-Husband:

First name

Middle name

Last name

Stipulation for

Temporary Order

With Minor Children

Divorce-40101

Legal Separation-40201

Case No.

In 1, enter the requested information about the wife.

Dates of birth should be written in the following format: [month, day, year].

Include area codes with the requested phone numbers.

In 2, enter the requested information about the husband.

1.Wife:

Name Address Address City

Date of birth

Gross monthly

income $ Employer name

Address of payroll office City Phone

2.Husband: Name

State Zip

State Zip

Fax

Dates of birth should be written in the following format: [month, day, year].

Include area codes with the requested phone numbers.

Address

Address

City

Date of birth

Gross monthly

income $

Employer name

Address of payroll office City Phone

State Zip

State Zip

Fax

FA-4126V, 02/10 Stipulation for Temporary Order- With Minor Children

§§767.225 and, 767.34, Wisconsin Statutes

For A1, check a or b. If b, enter the monthly amount of maintenance and the month and year on which the payments will begin.

For A2, check a or b. If b, enter the monthly amount of maintenance and the month and year on which the payments will begin.

Enter the name, date of birth [month, day, year] for each child under the age of 18.

The parties agree that the following terms be in effect until the final hearing of this action except as modified by a future order of the court.

1.SUMMARY OF FINANCIAL AGREEMENTS

A.Maintenance. (Spousal Support)

The parties agree that temporary maintenance shall be paid as follows:

1.For the Wife:

a.	The wife gives up her right to receive maintenance at this time.
b.	The husband shall pay maintenance to the wife in the amount of $
	per month beginning on the first day of the month of		, 20		.

2.For the Husband:

a.	The husband gives up his right to receive maintenance at this time.
b.	The wife shall pay maintenance to the husband in the amount of $
	per month beginning on the first day of the month of		, 20		.

B.Minor Children. The following minor children (age 17 or younger) born to or adopted together by the parties before or during the marriage are:

Name of Minor Child		Date of Birth

In C, check a, b, c, or d. You may check both b and d if both apply; otherwise, check only one box.

If b, enter who will provide insurance, the out of pocket cost for such insurance, and the amount the other party will contribute.

If c, indicate who will enroll the child in public health insurance and any out of pocket costs.

NOTE: Child Support generally includes costs for food, shelter, clothing, transportation, personal care and incidental recreational costs.

C.Medical and Health Care Expenses.

1.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 agree 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

a.	both parties. They shall provide private health insurance and neither parent is
	required to make a cash contribution to the other.
b.		.				He/She 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 included as a deviation in the child support
	calculation in D. Child Support Basis below.
c.	A comprehensive private health insurance policy is not available to either
	parent at a reasonable cost. The					mother			father		has enrolled in
		shall promptly apply for Public Health Insurance.
	1.	There is no out of pocket expense for the above Public Health Insurance.
	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 D.Child Support Basis below. If an accessible
		private health insurance policy becomes available at a reasonable cost
		to either parent, that parent shall enroll the child(ren) as covered
		dependents under his/her health insurance.

Enter the percentage that each parent will pay in a and b. The total must equal 100%.

Enter the number of days for the deadline.

In D, check the appropriate method of calculation for child support.

d. The mother father 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. He/She shall inform the child support agency about any change in his/her employment and the availability of insurance.

2.Uninsured Health Care Expenses. Payments for health care expenses for the minor children not covered by insurance, including medical, dental, orthodontic, hospital, psychiatric, counseling, drug and other health expenses shall be paid as follows:

a.	The wife to pay			% of the total amount.
b.	The husband to pay			% of the total amount.

3.Reimbursements. Any request for reimbursement from the other party for medical insurance and uninsured health care expenses shall be made in writing. The other

party shall pay their required percentage within		days after receiving a written
request.

D.Child Support Basis.

1.Calculation of child support. The child support percentage of income standards, the standard calculation, based on gross income 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.

In 2.a, enter payer’s name, recipient’s name, payment

frequency (weekly, bi- weekly, monthly, bi- monthly) and standard child support amount in a.

In b1, enter the medical deviation from C.1.b or 0 or none. In b2, enter the other deviations or 0 or none.

In c, enter the date the payment begins and determine the net child support amount after adding or subtracting the deviations from the amount in 2a.

In E, check 1, 2, or 3.

If 1 or 2, contact your local Child Support Agency to establish a WISCTF account.

Parties may not make payments directly to each

other. (See WI Stat. §767.75)

31% for four children.	low-income payer formula.
34% for five or more children.	high-income payer formula.

2.Child Support Order and Basis for a Deviation.

a. Based on the above standard calculation, the parties understand

that child support would be paid by
to	per	in the amount of $

b.The parties agree to deviate from that amount of child support.

1.A cash contribution from above in

C.1.b. or C.1.c.2. MEDICAL AND HEALTH CARE EXPENSES

increases decreases this child support amount by

(If no deviation, enter “0” or “None”) $

2.A deviation is based on: (Explain the reasons for any other deviation

	here)					and
	this		increases	decreases this child support amount by				$
c. The net amount of the child support payment shall begin							,
20			in the amount of
				(If no child support is to be paid, enter “0” or “Held Open”)				$

E.Payments for Child Support and/or Maintenance shall be made to the Wisconsin Support Collections Trust Fund (WI SCTF)

1.	directly from the payer to WI SCTF (only if self-employed).

2. by income assignment from the payer’s employer as indicated on page 1.

3. No child support or maintenance is to be paid at this time. F. Information about how payments are made to WI SCTF.

All payments for child support and/or maintenance ordered shall note the case number and the names of the parties on the face of the check should be made payable to WI SCTF, and sent to:

Wisconsin Support Collections Trust Fund

Box 74200

Milwaukee, WI 53274-0200

In 2.A, check 1 or 2.

If 2, check a ,b, c or d.

If a, b, or d enter the date [month, day, year].

In 3, check a, b or c.

If c, enter the date.

In 4, check a or b. If a, attach agreed upon arrangements.

The WI SCTF will transmit the payments to the proper persons entitled to them.

Failure of an employer to pay the proper amount shall not be a defense for failure to pay the proper amount. If an employer fails to take out the correct amount for child support and/or maintenance, the party paying is responsible for the full and correct amount.

The party paying child support and/or maintenance is responsible for payment of the annual receiving and disbursing fee to WI SCTF.

2.SUMMARY OF OTHER AGREEMENTS A. Residence.

1. The parties do not own or rent a residence together.

2. The parties do own or rent a residence together and agree that

a.	the wife shall have temporary exclusive use of the residence and the husband
	shall leave the residence on or before			.
b.	the husband shall have temporary exclusive use of the residence and the wife
	shall leave the residence on or before			.
c.	both parties agree to share the residence.
d.	both parties agree to vacate and/or sell the residence by				.

3.Sale of Residence.

a. The parties do not own a residence.

b. The residence shall not be placed for sale at this time.

c.

The residence shall be placed for sale no later than

.

4. Other Real Estate.

One or both of the parties own additional real estate, the agreement for temporary use of which is disclosed as an attachment.

a. Yes, see attached agreement. b. No

In B, check 1 or 2.

If 2, complete the chart indicating who has and who will have possession while the case is pending.

Complete this section with as much detail as possible.

NOTE: There are two

types of property. “Real estate” includes such

things as homes and land.

“Personal property” includes all other things such as vehicles, clothing and other personal items, furniture, bank accounts, and retirement or investment accounts.

NOTE: If you have already divided the property, you must still disclose how you divided it below.

B.Personal Property Division. The parties agree that the wife shall be awarded the temporary exclusive use of the personal property in her possession and the husband shall be awarded the temporary exclusive use of the personal property in his possession

1. with no exceptions.

2. except for the following property:

	List the property and check if the wife			Who will have possession?
	or husband will have temporary use of
	the property until the divorce/legal			Wife = W	Husband = H
	separation is final.
	Household Items						W			H
	Automobiles						W			H
	Year, Make, Model
	Life Insurance						W			H
	Name of Company & Policy #

Enter the date and describe arrangements for property exchange.

In C.1, write the name, monthly payment, and check who will be responsible for payment for each debt owed individually and jointly.

NOTE: Any and all debts disclosed on the parties’

Financial Disclosure Statements that are still unpaid should be included here and divided between the parties. Any new debts incurred should also be listed and divided.

If more space is necessary, attach additional sheets.

	Business Interests					W			H
	Name of Business & Address
Securities: Stocks, Bonds, Mutual Funds, Commodity Accounts						W			H
	Name of Company & # of shares
	Pension, Retirement Accounts,
	Deferred Compensation, 401K Plans, IRAs, Profit Sharing, etc.					W			H
	Name of Company & Type of Plan
	Cash and Deposit (Savings & Checking) Accounts					W			H
	Name of Bank or Financial Institution
	Other Personal Property					W			H
	Description of Asset
						See attached
Any exchange of property shall be made by (Date)
according to the following arrangements:

C.Debts and Liabilities.

1.Each of the parties shall be responsible for the following debts and liabilities to keep payments current:

		Payment to		Monthly	Paid by		Paid by		Shared
Payment for		(Creditor)		Payment	Wife		Husband		Equally
Mortgage/Rent			$
Mortgage/Rent			$
Car 1			$
Car 2			$
Car 3			$
Insurance (Auto)			$
Insurance (Medical)			$
Insurance (Life)			$
Loans-Student			$
Loans-Personal			$
Loans-Other			$
Credit Card 1			$
Credit Card 2			$
Credit Card 3			$
Credit Card 4			$
Other			$
Other			$