FAMILY COURT PROGRAM PAYMENT FORM All mediation/custody evaluation services provided by the Family Court Program are on a fee basis. The fees established are the following: Mediation Fee: $200.00 Court Ordered Custody Evaluations: $30.00 per hour $700.00 retainer fee upfront ($350.00 per parent) The fee is payable in advance of service, directly to the Outagamie County Clerk of Courts, Outagamie County Justice Center, 320 S. Walnut Street, Appleton, WI 54911. Payment cannot be accepted at the Family Court Program office. The Clerk of Courts will accept personal checks, cashier’s checks, cash or money orders. Checks should be made payable to Outagamie County Clerk of Courts. If you feel that you are unable to afford the entire fee, you may complete a request form to have the fee waived. The determination of a waiver is made by the Family Court Commissioner. The form is available through the Family Court Program. Questions pertaining to fees can be directed to the program at (920) 832-5660 between 8:00 a.m. and 4:30 p.m. Monday through Friday. ______________________________________________________________________ Court File No. _______________ Use this form for payment to the Clerk of Courts. Payment should be made at the earliest possible opportunity in order to have a mediator assigned to work with you. This payment form will be filed in the Family Court Program office after validation by the Clerk of Courts. Name & Address of Payer: _____________________________________________________ Name & Address of Other Parent: _____________________________________________________ Amount Enclosed: ______________________ Payment for: _____ Mediation Date Paid: _______________ _____ Custody Evaluation NOTE: If any portion of the fees were waived, please attach a copy of the waiver form. American LegalNet, Inc. www.USCourtForms.com