Wisconsin Fa 604 Form – Fill Out and Use This PDF

	Enter the name of the		STATE OF WISCONSIN, CIRCUIT COURT,
	county in which the						COUNTY
	original case was filed.
	Mark marriage or
	paternity. If paternity,		In RE: The	marriage	paternity of
	enter initials of child.
	Enter the name, address,	Petitioner/Joint Petitioner:
	and daytime phone
	number of the petitioner
			First name	Middle name		Last name
	or joint petitioner from
	the original case file.
			Current Mailing Address
	On the far right, mark
	the box for the change(s)
			City	State	Zip	Daytime phone number
	you are requesting and
			vs.
	enter the original case
	number.

FOR OFFICIAL USE

Stipulation and

Order to Change:

Legal Custody

Enter the name, address, and daytime phone number of the respondent or joint petitioner from the original case file.

Mark if the State of Wisconsin is a party or not. If you are unsure, you may call your local Child Support Agency.

Respondent/Joint Petitioner:

First name		Middle name	Last name
Current Mailing Address
City	State	Zip	Daytime phone number

The State of Wisconsin (Child Support Agency)

is

is not a party to this action.

Physical Placement

Child Support

Maintenance

Family Support

Arrears Balances

Other:

Case No.

In 1A and B, complete the gross income (before taxes) for both parties.

In C, enter the number of children subject to child support.

In D, check 1 or 2 to indicate if private health insurance is available. If 2, indicate who provides the insurance and how much it costs.

In 2, check all that apply in A-I. If I. enter the change in circumstance that has prompted you to make this agreement.

Findings/Basis: The parties agree that the requested changes are based on the following facts:

1.Current Income and Other Information

A. Wife/Mother			Gross monthly income $				Employer
B. Husband/Father			Gross monthly income $				Employer
C. Parties have				children subject to the child support standard.
D. Health insurance for the children.
1.	A comprehensive private health insurance policy is not available to either parent at a
	reasonable cost and/or neither parent’s income is currently more than 150% of the
	federal poverty level.
2.					provides health insurance at the cost of $					per
					.

2.Basis for Change

This agreement is based on the following substantial change in circumstance(s) that have occurred since the entry of the prior court order in this case:

A.	a child who was living with							is now living with		.
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 was not a placement schedule and the parties could not agree.
E.	the availability or cost of health insurance has changed.
F.	employment or work shift of							both parties has changed.
G.	income or wages of							both parties has changed.
H.	the party to whom maintenance is owed has remarried.
I.	Other:
									See attached

If you are modifying financial orders, check

1.Complete all sections you are changing in 1A- 1H.

If you are changing child support, check 1.A. In 1, enter the current child support order and check a or b. If b, check 1 or 2 and complete as required.

In 2, check the standard calculation 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.

Enter support amount based on standard calculation, frequency of payment and which party is paying. Check a or b. If b, check 1 or

2.If 2, explain and indicate the new child support amount based on the deviation.

If you are changing any category in B-G, check the type of support you are changing.

In 1, enter the current order by indicating the current support amount, the frequency of payment, and the name of party who currently pays or owes the money.

In 2, indicate the month, day and year the new payment should begin and what you have agreed to change the support amount to by checking a or b. If b, enter the amount of the order, the frequency of the payment, and indicate which parent will be making the payments.

Agreements: The parties agree that the judgment or order in this case should be changed as follows, and that the court may enter this stipulation as an order without a court hearing.

1. Modify Current Financial Order(s) A. Child Support

1. Is currently

held open ($0)

$

% per

. The

amount is paid by

to

. This

child support order

a. did not deviate from the percentage standard for any reason.

b. did deviate from the percentage standard when it was set because:

1.

The cost of health insurance paid by

.

2. Other reasons as follows:

2.Shall be changed to a new amount that is based on the gross income above and the following percentage of income standard:

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.

*Shared-placement or Split-placement:

Describe or attach the placement percentage of time with each parent.

See attached

**Serial-family parent:

Describe or attach the calculation.

See attached

Based on this standard, the support order in this case would be $

per

and paid by

to

.

We agree to

a.

set support based on this standard beginning

, 20

.

b.

deviate from the amount of support calculated above because:

1.

A cash medical contribution toward the cost of medical and health expenses

increases decreases this child support amount by $

per

.

2.

Other (explain the reason you agree support should be different than the standard amount)

This other deviation increases decreases the standard amount by

$.

			After calculating the deviation(s), we agree to set child support to $
			per							and paid by											to
			beginning													, 20											.
B.	Maintenance
	1.	That is currently								$0	$									% per												and paid
		by (Name)														.
	2.	Shall be changed to the following beginning																												, 20
		a.	$0.
		b.	$								% per						and paid by (Name)													.
C.
	Family Support
	1.	That is currently								$0	$																	%		per
		and paid by (Name)																			.
	2.	Shall be changed to the following beginning																												, 20
		a.	$0.
		b.	$					per					and paid by (Name)																								.

D.

Arrears Payment

1.That is currently

(Name)

$0

$

.

% per

and paid by

G.

Child Support Interest Arrears Balance
1.	That is currently				$0	$			and owed by (Name)	.
2.	Shall be changed to the following beginning									, 20
	a.	$ 0.
	b.	$

If I, describe the other financial agreements in as much detail as possible. Include amounts, dates, names, etc.

In 2, check A or B.

If B, check 1 or 2.

If 2, complete the payer’s employer

information. In 3, if you are requesting changes to physical placement check A and enter the names of the children for whom you have agreed to changes.

Check 1, 2, 3, or 4, enter the parents’

names as requested and enter or attach the new placement schedule.

H.	Other Arrears Balance
	1.	For (type(s) of arrears)								that is currently
		a.	$0.
		b.	$		owed by (Name)
	2.	Shall be changed to the following beginning						, 20
		a.	$0.
		b.	$

I. Other Financial changes as follows:

2.Payments shall be made

A. no payments are ordered.

B.

to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee,

Wisconsin 53274-0200

1.

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

2.

by income assignment from the payer’s employer as indicated below:

Employer name

Address of payroll office

City

State

Zip

Phone

Fax

3.Modify

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

If making a change to terms of placement related to supervision, check 5 and complete all relevant information. If other, check 6 and enter the specific information.

If you are requesting changes to legal custody check B and enter the names of the children for whom you have agreed to changes. Check 1, 2, or 3 and enter the requested information.

If you are modifying anything else, check and complete 4.

4.

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

The new 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

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:

See attached

4. Additional changes as follows:

See attached

THE COURT ADOPTS AS FINDINGS THE FACTS SET FORTH ABOVE.

THE COURT FURTHER FINDS:

For Court Use Only.

Deviation from the child support percentage standards meets the requirements of §767.511(1n), Wisconsin Statutes.

1.Amount support would be using percentage standard is as set forth in Agreements 1.A.2.

2.Amount support deviates from percentage standard is as set forth in Agreements1.A.2.b.

3.The percentage standard is unfair

for the reasons set forth in 1.A.2. Other:

4. The basis for the modification is

as set forth above. Other:

THE COURT ORDERS:

1.This stipulation is approved and the previous judgment or order is amended accordingly.

2.All provisions of the previous judgment or order not amended by this order remain in full effect.

3.Whenever private, accessible and reasonably-priced health insurance becomes available to either parent at a reasonable cost, that parent shall enroll the child(ren) as covered dependents under his/her health insurance, unless the child(ren) are already enrolled under another private health insurance plan or unless the parent's income is below 150% of the federal poverty level.

The former wife/mother must sign and print her name.

Enter the date on which she signed her name.

NOTE: This signature does not need to be notarized.

The former husband/father must sign and print his name.

Enter the date on which he signed his name.

NOTE: This signature does not need to be notarized.

If either party is receiving public assistance or there is a case worker from the Child Support Agency assigned to your case, you must take this agreement to the Child Support Agency in your county for their approval.

If not, mark not required.

If a Guardian ad Litem has been appointed to your case, you must take this agreement to the GAL for his/her approval.

If not, mark not required.

For Court Use Only.



Wife/Mother

Print or Type Name

Date



Husband/Father

Print or Type Name

Date

State of Wisconsin, Child Support Agency

Approved

Not Approved

Not Required

Authorized Signature

Print or Type Name

Date

Guardian ad Litem

Approved

Not Approved

Not Required (No GAL has been appointed)

Authorized Signature

Print or Type Name

Date

BY THE COURT:

Circuit Court Judge

Circuit Court Commissioner

Print or Type Name

Date