Request for Judicial Review of FCS Fee Decision Your Name:_______________________________ Name of other parent _______________________ Case Number: ________________ Based on our combined households' income, FCS has set the total fee at $_______. I am required to pay $______ of the total fee. The date I was informed of this decision was ___________. _____ I object to the total payment tier that has been determined. _____ I object to the amount I am required to pay. _____ I object to the allocation of the payment between myself and the other parent. I request that the matter be reviewed by the Family Court Commissioner and a hearing scheduled if necessary. ____________________________________ Signature ______________________ Date You must attach a complete Financial Disclosure Statement, copies of your 3 most recent pay stubs from employment and a copy of your most recent tax return, with this request in order for it to be considered. If you are remarried, you must also attach copies of pay stubs and copies of the most recent tax return for your spouse, if you reside in the same household. You must also attach a copy of the Application to Set and/or Waive Family Court Services Fee that was submitted to FCS. Per local rule 407, any party may seek a review of the FCS fee determination by making a written request to the Family Court Commissioner within 15 days of being notified of their responsibility for payment. The completed documentation may be mailed to: Dane County Clerk of Courts Attention: Lead Court Commissioner, 215 South Hamilton Street Room 2000, Madison, WI 53703. Adopted 01-20-09, modified 07-11-14 American LegalNet, Inc. www.FormsWorkFlow.com