Fa 4147V Form – Fill Out and Use This PDF

Check Petitioner Petitioner/ Joint Petitioner A or Respondent/Joint Petitioner B.

NOTE: Legal custody is the right and responsibility to make major decisions about a child, except for those specific decisions described in 2, if any.

Enter the name of each child and check who you believe should have legal custody.

I understand that Wisconsin law states that in an action in which legal custody or physical placement is contested:

I am required to file a proposed parenting plan within 60 days after the court waives mediation or within 60 days after the mediator notifies the court that no agreement has been reached.

I am required to submit a proposed parenting plan to the mediator at least 10 days before the initial mediation session.

If I fail to file such a plan, I may lose my right to contest the plan submitted by the other parent unless I can show good cause for my delay.

I am	Petitioner/Joint Petitioner A	Respondent/Joint Petitioner B of the minor children
of this case.

I AM PROPOSING THE FOLLOWING PARENTING PLAN:

A.Legal Custody

1. Legal custody of the minor children shall be as follows:

Sole

Sole

Name of Child

Date of

Joint Legal

Legal Custody

Legal Custody to

Birth

Custody

Petitioner/

Respondent/

Joint Petitioner A

Joint Petitioner B

Check who will be making the specific decisions for each subject area in a-d. If other, please specify.

2.Specific Decision Making Authority

Decisions in the following listed areas will be made as follows:

	Decision		Jointly		Petitioner/		Respondent/
					Joint Petitioner A		Joint Petitioner B

a. Non-Emergency Health Care

b. Education/School Activities

c. Child Care Providers

d. Non-School Activities

e. Other:

NOTE: Physical Placement is the right to have a child physically placed with a party.

Enter the name of each child and check which parent you believe should have physical placement of that child.

In allocating the time the minor children spend between the parents, the court should award the placement on a day-to-day basis as follows:

							Primary Physical			Primary Physical
	Name of Child			Equal Shared			Placement to			Placement to
				Placement			Petitioner/			Respondent/
							Joint Petitioner A			Joint Petitioner B

Check 1 or 2. If a, attach a schedule. If b, describe how placement will be shared in the chart provided.

If checked, enter reasons.

Check if attachments.

Check 1, 2 or 3.

If 1, enter the year [every/odd/even] in which the schedule will begin. Check which parent you believe should have the children for each holiday break.

AND the physical placement schedule shall be:

1. as listed in the attached document.

2. as proposed below (on a biweekly basis):

Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.

Week 1

Week 2

If either parent is receiving less than 25% physical placement with the minor

child(ren), the specific reasons more placement with that parent is not in the child(ren)’s best interest is as follows:

See attached

C.Summer and Holiday Placement Schedule

The summer and holiday placement schedule should be as follows:

1. as proposed here:

			With Petitioner/			With Respondent/
			Joint Petitioner A			Joint Petitioner B
HOLIDAYS			the following years			the following years
			Every	Even	Odd	Every	Even	Odd
			year	years	years	year	years	years
a. Mother’s Day
b. Memorial Day
c. Father’s Day
d. July 4th
e. Labor Day
f. Halloween
g. Thanksgiving
h. Christmas Eve
i. Christmas Day
j. New Year’s Eve
k. New Year’s Day
l. Religious Holiday
m.Religious Holiday
n. Petitioner/Joint Petitioner A’s Birthday
o. Respondent/Joint Petitioner B’s Birthday
p. Children’s Birthday(s)

If 2, write the name of the county whose schedule you are using.

If 3, enter the other schedule.

Check 1 or 2.

If 2, enter the name of the childcare provider and indicate in a and b the percent you propose each parent should pay toward the cost. The total amount must equal 100%.

Check a, b, c, or d.

If c, check 1 or 2.

If d, enter the other proposal.

For 2, check a, b, or c.

If b or c, enter the location for the drop-off.

If d, check 1,2,3 or 4. For each enter the requested information.

For 3, check a or b. If b, enter how you propose the transportation costs should be paid.

Enter the name of each child and indicate which school you propose he/she attend.

Enter the percentage each parent should pay. The total amount must equal 100%.

q. Other:

r. Other:

s. School Spring Break

t. School Teacher Conventions

u. Summer Break to be shared as follows:

2. According to the attached

County standard placement schedule.

3. Other:

See attached

D.Child Care

1.	The children do not require child care.
2.	The child care will be provided by
	And the cost of child care will be paid as follows:
	a. Petitioner/Joint Petitioner A to pay				%.
	b. Respondent/Joint Petitioner B to pay					%.

E.Transportation Issues

1. The physical transfer of the children for placement should be as follows:

a. All transportation to and from placements will be provided by Petitioner/ Joint Petitioner A.

b. All transportation to and from placements will be provided by Respondent/ Joint Petitioner B.

c. Transportation will be shared with:

1) parent with children shall deliver.

2) parent without children shall pick up.

d. Other:

2. Transfers of children shall take place at:

a. parent’s home.

b. halfway point: c. other location:

d. Inter-spousal battery/domestic violence is an issue in this relationship and in order to ensure the safety of the children and/or parent, transfers of the children between the parents shall be:

1) supervised by

2) at a neutral public site

3) at a home of the following person

4) Other:

3. Transportation Costs shall be:

a. paid by party who incurs the costs. b. paid as follows:

F.School

1.The children will attend school at:

Name of Child	School/ School District

Check a or b.

If a, enter the address.

If b, enter your general location.

Check a or b. If a, enter the address at which you intend to live for the next two years.

If b, enter the general location of where you intend to live for the next two years.

Check 1 or 2.

If 1, enter your current employer and your general work schedule.

If 2, enter your general employment.

Enter the name of each provider. If other, enter the description along with the provider name.

In J., check all that is applicable. Use “Other” to

indicate additional variable expense that is not listed.

2.	Education costs will be paid as follows:
	a. Petitioner/Joint Petitioner A to pay			%.
	b. Respondent/Joint Petitioner B to pay				%.
G. Residence
1.	Current
	a. I currently reside at:

Address

CityState Zip

b. This is a domestic violence case; I decline to give a specific address, but

my general location is currently					.
c. The other party resides at:
Address
City				State		Zip
2. Future

a. For the next two years it is my intention to reside at: Address

CityState Zip

b. This is a domestic violence case; I decline to give a specific future address, but it is my intention to generally reside for the next two years at:

.

H.Current Employer

1.

I am currently employed at:

Employer

City

State

Days/Hrs.

2.

This is a domestic violence case; I decline to give my specific employment, but

where I generally work is

.

3. The other party is currently employed at:

Employer Name

Address

City

State

Zip

I.Health Care

Providers: Healthcare services will be provided to the children by the following: Doctors/Pediatrician/Clinic

Eye/Optometrist

Dentist/Orthodontist Insurance/Health Plan (if any) Other:

J.Variable Expenses

I expect the child(ren) to incur the following variable costs:				See attached
CHILDCARE			Yes	No	N/A
day care
Other:
Other:
TRANSPORTATION			Yes	No	N/A
driver’s education fees
child’s car insurance
child’s vehicle

Check 1 or 2.

If 1, enter the name of the religion.

Check all that apply in 1-

10.If other, enter a description.

K.Religious Upbringing

1. The minor children will be raised in the following religion:

2. No religious affiliation is planned.

L.Maintaining Contact with Other Parent

I shall assist the children in maintaining contact with the other parent by:

1. direct contact through periods of placement.

2. telephone contact.

3. cards/letters.

4. e-mail.

5. providing copies of children’s school projects.

6. providing photographs of children participating in activities.

7. assisting children with gift purchasing for other parent for birthdays and holidays.

8. assisting children with letter writing to other parent.

9. creating personal web-site for posting pictures, letters, information, comments.

10. Other:

(Note: Each parent is expected to take personal responsibility for contacting the schools to obtain school calendars and report cards and attending parent- teacher meetings.)

Check all that apply.

If 8, enter the name(s) of the individuals.

If 10, enter your suggested method.

Enter the date on which you signed your name.

NOTE: This signature does not need to be notarized.

Check box if a lawyer mediator helped to complete this form.

M.Resolving Disagreements

If there are disagreements between myself and the other parent on issues that are to be joint decisions, the way to resolve the disagreements will be

1. the parent who has primary physical placement will decide.

2. the parent who has physical placement at the time of the disagreement will decide. 3. to allow the parent who generally made this type of decision before these court

proceedings were started to make the same type of decision in the future. 4. to review the issues from the other parent’s or children’s standpoint and

reconsider my position.

5. to determine whether my opposition is in good faith and in the best interests of the children or whether it is an attempt to spite the other parent.

6. to determine whether this is a situation in which the children is/are attempting to manipulate one parent against the other and, if so, consult with the other parent.

7. to ask for assistance from friends, relatives, clergy, or others who can be neutral and fair.

8. I would suggest the following person(s) to serve as a third-party neutral(s):

9. to contact the family court mediation program.

10. Other:



		Petitioner/Joint Petitioner A OR		Respondent/Joint Petitioner B
		Name Printed or Typed
		Address
Email Address				Telephone Number
Date				State Bar No. (if any)

This document was prepared with the assistance of a lawyer acting as mediator.