Fill Out Your Wisconsin Fa 604 Template

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:

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

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:

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

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

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

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:

This other deviation increases decreases the standard amount by

$.

D.

Arrears Payment

1.That is currently

(Name)

$0

$

.

G.

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.

I. Other Financial changes as follows:

2.Payments shall be made

A. no payments are ordered.

3.Modify

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.

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:

Print or Type Name

Date