Form Fa 4171V – Fill Out and Use This PDF

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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

joint petitioner from the

First name

Middle name

Last name

original case file.

On the far right, mark the

Current Mailing Address

box for the change(s) you

are requesting and enter

City

State

Zip

Daytime phone number

the 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

The State of Wisconsin (Child Support Agency)

Wisconsin is a party or

not. If you are unsure,

is

you may call your local

is not a party to this action.

Child Support Agency.

Location

Date

Time

a.m./p.m., or as soon as the matter may be heard,

1.

from primary physical placement with (Name of Parent)

to primary placement with (Name of Parent)

2.

from shared placement to primary placement with (Name of Parent)

3.

from primary placement to shared placement.

4.

from the current shared placement schedule (if any) to a new shared placement

schedule.

The requested placement schedule for the changes in 1-4 above is as follows:

See attached

5.

to require placement with (Name of Parent)

be

supervised.

unsupervised.

6.

Other:

See attached

The other party and I

attempted mediation on (Date)

.

have not attempted mediation for this issue.

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

1.

to joint legal custody with both parents.

2.

to sole legal custody with (Name of Parent)

3.

Other:

a. that is currently $

per

that

1.

does not include a deviation for health insurance or any other reason.

2.

does include a deviation of $

upward

downward for

health insurance.

b. To a new amount beginning

to be paid by (Parent)

to (Parent)

1.

based on state child support standards determined by the court.

2.

a new set amount of $

per

.

3.

held open (no payment).

I request that this new amount

A.

not include a deviation for health insurance or any other reason.

B.

include a deviation of $

upward

downward as a cash

contribution for health insurance.

2.

Maintenance (Spousal Support) that is currently $

per

to

a.

an amount beginning

, 20

to be determined by the court

based on current income.

b.

a new set amount of $

per

beginning

, 20

.

3.

Arrears payment that is currently $

per

to

a.

an amount beginning

, 20

to be determined by the

court.

b.

a new set amount of $

per

beginning

, 20

.

4.

Arrears balance as it is currently reflected in the WI SCTF KIDS computer

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.

B.

A child is no longer eligible for child support because 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 different 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 availability or cost of health insurance has changed.

H.

The party to whom I owe maintenance has remarried.