GN-4530, 05/18 Revised Reimbursement Order (Chapter 55) 24755.107, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Revised Reimbursement Order (Chapter 55) Case No. Based on the response of the state public defender, THE COURT ORDERS: 1. The ward is A. indigent. The Order for Reimbursement for Costs of Representation is revised to require no reimbursement. B. partially indigent. The Order for Reimbursement for Costs of Representation is revised to order reimbursement in the amount of $ , not to exceed $120. C. not indigent. The reimbursement as set forth in the Order for Reimbursement for Costs of Representation, including the payment schedule, remains in effect; OR No reimbursement was previously ordered. The ward to reimburse the State of Wisconsin for costs of representation in the total amount of $ , not to exceed $480. 2. The ward is ordered to pay as follows: The total amount of $ is due in full by ; OR The total amount of $ is to be paid at a rate of $ /month starting on and on the day of each month thereafter until paid in full. 3. Payment made to: 4. Other: THIS IS A FINAL ORDER FOR THE PURPOSE OF APPEAL IF SIGNED BY A CIRCUIT COURT JUDGE. DISTRIBUTION: 1. Court 2. 3. 4. Corporation Counsel 5. Social worker/ County Dept. of Human Services 6. Spouse/Adult Children/Parent of Minor 7. Facility, if any 8. Other: American LegalNet, Inc. www.FormsWorkFlow.com