Fa 4175V Form – Fill Out and Use This PDF

	PRINT in INK
	Enter the name of the		STATE OF WISCONSIN, CIRCUIT COURT,
	county in which the						COUNTY
	original case was filed.
	Check marriage or		In RE: The	marriage	paternity of
	paternity. If paternity,
	enter initials of child.
	Enter the name, address,		Petitioner/Joint Petitioner:
	and daytime phone
	number of the petitioner or
			First name	Middle name		Last name
	joint petitioner from the
	original case file.
			Current Mailing Address
	On the far right, mark the
	box for the change(s) you
	requested and enter the		City	State	Zip	Daytime phone number
	original case number.		vs.
			Respondent/Joint Petitioner:
	Enter the name, address,
	and daytime phone		First name	Middle name		Last name
	number of the respondent
	or joint petitioner from the		Current Mailing Address
	original case file.
			City	State	Zip	Daytime phone number
	Check if the State of
	Wisconsin is a party or		The State of Wisconsin (Child Support Agency)
	not. If you are unsure,		is
	you may call your local		is not a party to this action.
	Child Support Agency.

For Official Use

Decision & Order on

Motion or Order To Show

Cause to Change:

Legal Custody

Physical Placement

Child Support

Maintenance

Other:

Case No.

Enter the name of the court official who held the hearing and the address and date [month, day, year] on which it was held.

Check one box from 1 and check A or B.

If B, enter the name of the attorney.

Check one box from 2 and check A or B.

If B, enter the name of the attorney.

DECISION AND ORDER ON MOTION or ORDER TO SHOW CAUSE

HEARING

A hearing was conducted in this matter as follows:

1. Before

Circuit Court Judge

Circuit Court Commissioner

2.Location

3.Date

APPEARANCES

1.	Former Wife/Mother
	appeared in person		appeared by phone		did not appear	AND
	A.	was self-represented.
	B. was represented by Attorney					.
2.	Former Husband/Father
	appeared in person		appeared by phone		did not appear	AND
	A.	was self-represented.
	B. was represented by Attorney						.

In 3, check A, B, C, or D.

If B, C, or D, enter the name of the individual

3.Others appearing at the hearing:

A. None.

B.	Child Support Agency by			.
C.	Guardian ad Litem (GAL)			.
D.	Other:			.

In 1, check A, B, or C.

Check A if the court denied the request to change the order.

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.

Based on the findings and reasons stated, IT IS ORDERED:

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.

B. DEFERRED to collect more information. Before making a final decision the court orders the following:

1. The parties attend mediation with

a. no payment is required.

b.

wife/mother to pay $

towards the mediation fee by

.

c.

husband/father to pay $

towards the mediation fee by

.

2.

Attorney

be appointed as GAL and

a.

no payment is required.

b.

wife/mother to pay $

towards the GAL fee by

.

c.

husband/father to pay $

towards the GAL fee by

.

3. A physical placement study be conducted by

a. no payment is required.

b.	wife/mother to pay $			towards the study fee by				.
c.	husband/father 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.

If 2, enter the children’s names and check all that apply in a-c.

C.

GRANTED as follows:

1. Physical Placement Order(s) (time with children) for the following children:

a. from primary physical placement with to primary placement with

b. from shared placement to primary placement with

c. from primary placement to shared placement.

d. from the current shared placement schedule 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

2.	Legal Custody (decision making) for the following children:

a. to joint legal custody with both parents.

b. to sole legal custody with

c. Other:

See attached

Check a, b, c, or d.

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 be responsible for providing public health insurance and whether the children are enrolled or need to need to be enrolled.

Also, check 1 or 2. If 2, indicate the cost for such insurance and the amount the other party will contribute,

If d, check which party has income below 150% of the federal poverty level.

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 physical placement of the children.

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 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

4.B. of 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 4.B. of Child Support Basis 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.

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.

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.

In B.1, 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.

In C-G, if applicable, enter how the court ordered the payments to be made.

In H, enter any other financial orders.

B.Child Support Order and basis for a Deviation.

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

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

2.The court orders a deviation from that amount of child support. a. A 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. 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”)

Maintenance to $

C.

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 as indicated below:

Employer name

Address of payroll office

		City			State			Zip
		Phone			Fax
H. Other financial order(s):

In 5, enter any non- financial orders.

In 6, check A or B.

A.

If B, enter the date and B.

time of the review hearing, the judge who will preside, and the room number where the hearing will take place.

See attached

5. Other non-financial order(s):

See attached

6.A future hearing

A.	is NOT required.
B.	is set for (Date)			time			am./pm.
	before			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.

For Court Use Only.

Circuit Court Judge

Circuit Court Commissioner

Name Printed or Typed

Date