Contempt P-3101 Court Related Offices Court Self-Help Center Courthouse, Room C-108 262-548-7524 http://courtselfhelp.waukeshacounty.gov Hours of Operation: Walk-ins: Mon. Wed. Fri. 8:30 am - 12 pm 12:00 pm - 4 pm 8:30 am - 4 pm By Appointment: By phone: Tues. 12:30 pm - 4 pm Tues. 9:00 -10:00 am Thurs. 8:30 am -12 pm Thurs. 2:00 - 3:00 pm Family Legal Clinic: Wednesdays 4:30-6:30 pm (by appointment only) 20 minutes of free legal advice Child Support Agency Administration Building, Room 348 414-615-2586 Open: Mon-Fri 8 am - 4:30 pm Family Court Office Courthouse, Room C-112 262-548-7544 Open: Mon-Fri 8 am - 4:30 pm Waukesha County Courthouse, 515 W. Moreland Blvd, Waukesha, WI 53188 Notary Public Services are available at no charge in the Family Court Office and Copies can be made in the Court Self-Help Center for $.15 per page This packet is used to seek assistance from the court if the other party has violated or not followed a court order or judgment related to any matter except physical placement of a minor child. If the violation is related to physical placement, please see P-3105- Enforcing Physical Placement. You are encouraged to seek some legal assistance to verify that these forms are the most appropriate for your situation. The Court Self-Help Center staff cannot give legal advice, but they can review forms for completeness and answer basic procedural questions. P3101 ▪ Contempt▪ Page 1 of 3 WCCSH Rev. 3/08 American LegalNet, Inc. www.FormsWorkflow.com Procedural Checklist Getting a Court Date 1. Complete the Order to Show Cause and Affidavit for Finding of Contempt (FA-4172). 2. Go to the Court Self-Help Center during regular business hours or call to make an appointment (see page 1) to have your forms reviewed for completeness. 3. Go to the customer service window of the Family Court Office. The clerks will: Collect the appropriate filing and copy fees. Assign you a court date. Make your copies. Return the appropriate number of copies to you. Caution! You may have to wait for court staff to obtain a court official’s signature. For best results, avoid the early morning, lunch hour, and late afternoons. Notifying the Other Party (Service) 4. Give the other party(ies) notice of the hearing by having him/her served with the Order to Show Cause and Affidavit for Contempt (FA-4172) and the Income Statement (FA4138). See the Service Packet for options and procedural instructions. Deadline: The other party(iess) must be personally served with the forms no later than five (5) business days before the date of the hearing. 5. Make a copy of the proof of service (Affidavit of Service or Admission of Service) for your records and bring the original to court on the date of the hearing. Warning: Without proof of service, the court cannot proceed with the hearing. NOTE: If, for any reason, you need to cancel or postpone your court hearing, you must send a written request to the court and all parties (including the Child Support Division, if a party). Once the Court has made a decision, you must then notify the other parties of the Court’s decision and new date, if one was assigned. Preparing for and Going to Court 6. Take the following items with you to court: Original proof of service. Original and two (2) copies (3 if the State is a party) of your completed, dated, and signed Income and Expense Statement (FA-4138) and required attachments. Any other documents you think may help you make your case to the court along with copies for each party. If you wish to have other people testify for you, make sure they come to court in person. A letter from them is not acceptable. P3101 ▪ Contempt▪ Page 2 of 3 WCCSH Rev. 3/08 American LegalNet, Inc. www.FormsWorkflow.com 7. Go to the correct courtroom at least 20 minutes before your assigned court time and let the bailiff or court clerk know that you have arrived (you may sit in the hall or watch court). 8. When your case is called, present your case to the Judge/Court Commissioner: Be prepared to state your side of each issue clearly and completely. Be prepared to answer questions that may be asked of you by the Court or others. If you wish to offer written evidence or documents to the court, give the original to the court and a copy to the other side. While you are in court, use the forms you prepared as an outline to remind you of each issue you want to talk about. 9. The Judge/Court Commissioner will state his/her decisions/rulings to you. Take notes because you must be able to write the ruling on a specific form called Decision and Order (FA-4176). The court may also set another hearing for the parties to return to court. After Court 10. After your court hearing, complete the Decision and Order for Contempt (FA-4176). 11. Go to the Court Self-Help Center to have your form reviewed for completeness. 12. Make four (4) copies (5 if the State is a party) of the completed Decision and Order for Contempt. You should have at least 5 sets in all. 13. Before filing, send one copy under the 5-day rule to the other party and the State of Wisconsin, if a party. The five-day rule gives the other party 5 days to object to the accuracy of how you have written the order, not to what happened in court. 14. File the original, the remaining three copies of the Order, and two self-addressed stamped envelopes (one addressed to you, one addressed to the other party) in the Family Court Office in person or by mail. 15. The court will hold the Decision and Order for Contempt for five (5) days to give the other party(s) time to review the order and object to how accurately it has been completed. If there are no objections within the five days and the court agrees with how you have written the Order, the assigned court official will approve and send each party a signed copy. 16. If the other party is found to be in contempt of court, he/she may be given remedial sanctions or consequences for not complying with the original court order/judgment. He/she may also be given a certain amount of time to comply with specific actions to stop the contempt (also known as purge terms). The court official will give you instructions as to how to proceed from the date of the hearing. If the court does not give instructions, and the other party has not complied with the terms of the new order, you may write a letter to the court official explaining that the other party has not complied with the order and request action from the court. You must also send a copy of the letter you wrote to the court to the other party(s). P3101 ▪ Contempt▪ Page 3 of 3 WCCSH Rev. 3/08 American LegalNet, Inc. www.FormsWorkflow.com PRINT in BLACK ink Enter the name of the county in which the original case was filed. Check marriage or paternity. If paternity, enter initials of child. Enter the name, address, and daytime phone number of the petitioner or joint petitioner from the original case file. For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY In RE: The marriage paternity of: Petitioner/Joint Petitioner: First name Middle name Last name Current Mailing Address On the far right, enter the original case number. City State Zip Daytime phone number vs. Order To Show Cause and Affidavit for Finding of Contempt Respondent/Joint Petitioner: Enter the name, address, and daytime phone number of the respondent or joint petitioner from the original case file. First name Enter the name of the party you want to appear in court. For Court Use Only: This section will be completed by the court. Last name Current Mailing Address City Check if the State of Wisconsin is a party or not. If you are unsure, you may call your local Child Support Agency. Middle name State Zip Daytime phone number The State of Wisconsin (Child Support Agency) is is not a party to this action. Case No. ORDER TO SHOW CAUSE Upon the attached Affidavit, IT IS ORDERED THAT: appear in person at the following date and time: Before: Location: Date: a.m./p.m. , or as soon as the matter may be heard, Time: To show cause why YOU should not be found in contempt of court as requested in the attached affidavit. If you do not appear as indicated, the court may hold the hearing without you and grant the request, including issuing an order to have you arrested and committed to the county jail. You also have a right to be represented by an attorney at this hearing. Unless good cause is shown, failure to appear without an attorney will be deemed a waiver of that right. IT IS FURTHER ORDERED that: • A copy of this order to show cause and affidavit be personally served upon all other parties at least 5 business days before the date of the hearing. • Both parties bring to court a fully completed, dated, and signed Income and Expense Statement and all required attachments. BY THE COURT: Circuit Court Judge/Circuit Court Commissioner Name Printed or Typed For Court Use Only Date FA-4172V, 01/08 Order to Show Cause and Affidavit for Finding of Contempt §§767.451 and 767.59 , Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Order to Show Cause and Affidavit for Finding of Contempt Page 2 of 2 Case No. ____________ AFFIDAVIT FOR FINDING OF CONTEMPT Check all those categories for which you believe the other party is in contempt. If other, mark the box and write for what you believe the other party is in contempt. IF the issues are related to legal custody or physical placement of a child, the Notice of Hearing and Petition to Enforce Physical Placement form is available. Enter the date the current court order or judgment was signed by a court official. Enter the facts that support your claim. If you need additional space, mark the box and attach the sheets. 1. The other party was court ordered to do the following and has failed to do so: . per Pay child support in the amount of $ . per Pay maintenance (spousal support) in the amount of $ . per Pay family support in the amount of $ Pay uninsured medical bills in the total amount of $ . Copies of the unpaid bills are attached to this Affidavit. Return property that was awarded to me. Sign/complete final documentation (Quit Claim Deed, QDRO, WI Real Estate Transfer Return, vehicle titles, etc.). Pay debts that he/she was ordered to pay. to equalize the property settlement. Pay the amount of $ Allow me to claim the children as tax exemptions as ordered. Provide medical insurance cards and/or other medical records. Pay transportation expenses related to placement in the total amount of $ Other: Other: Other: Other: Other: . 2. The court order that I am asking to be enforced was dated: 3. The facts supporting my reasons for believing that the other party is in contempt are as follows: See attached If you need help in this matter because of a disability, please call: STOP! Take this document to a Notary Public BEFORE you sign it. After you have been sworn by a Notary Public, sign and print your name and date the document in front of the Notary Public. Signature Print or Type Name Date Subscribed and sworn to before me Have the Notary Public sign, date, and seal the document. on (Seal) Notary Public, State of Wisconsin My commission expires: A copy of this Order to Show Cause and Affidavit must be served upon all other parties at least 5 business days before the date of the hearing. See Service Packet for more information. FA-4172V, 01/08 Order to Show Cause and Affidavit for Finding of Contempt §§767.451 and 767.59 , Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com PRINT in BLACK ink Enter the name of the county in which the original case was filed. Check marriage or paternity. If paternity, enter initials of child. Enter the name, address, and daytime phone number of the petitioner or joint petitioner from the original case file. For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY In RE: The marriage paternity of: Petitioner/Joint Petitioner: First name Middle name Last name Current Mailing Address On the far right, enter the original case number. City State Zip Daytime phone number Decision & Order For Contempt vs. Respondent/Joint Petitioner: Enter the name, address, and daytime phone number of the respondent or joint petitioner from the original case file. Check if the State of Wisconsin is a party or not. If you are unsure, you may call your local Child Support Agency. STOP! Do not complete the remainder of this form unless required by the court official who is hearing this case. First name Arrest and Commitment Order 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. Case No. HEARING A hearing was conducted in this matter as follows: 1. Before: Circuit Court Judge/ Circuit Court Commissioner 2. Location: Enter the name of the court official who held the hearing and the address and date [month, day, year] of the hearing. Check one box from 1 and check a or b. If b, enter the name of the attorney. Check one box from 2 and check a or b. If b, enter the name of the attorney. Check a, b, c, or d. If b, c, or d, enter the name of the individual who appeared. 3. Date: APPEARANCES 1. Former Wife/Mother: appeared by phone appeared in person was self-represented. A. was represented by Attorney B. 2. Former Husband/Father: appeared by phone appeared in person was self-represented. A. was represented by Attorney B. did not appear AND . did not appear AND . 3. Others appearing at the hearing: None. A. Child Support Agency by B. Guardian ad Litem (GAL) C. Other: D. FA-4176V, 01/08 Decision & Order for Contempt . . . §767.78 Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Decision & Order for Contempt Page 2 of 3 Case No. ____________ FINDINGS and ORDER Enter the name of the party who was requested to be found in contempt. Check A or B. If B, check all that apply in 1-13 for which the party was found in contempt and enter the corresponding information. Check A, B, and/or C. If B, enter the number of days sentenced and check 1 or 2 to indicate if work release privileges were granted. If C, enter the other punishments. If B or C, complete D by checking 1 or 2 and entering the date. Check A, B, and/or C. If B, enter the amount and the method of payment the court ordered. If C, enter the other terms under which the party may get out of contempt. Mark how the court ordered the payments to be made. Based on the findings and reasons stated. IT IS ORDERED: be found in Contempt. 1. The Order to Show Cause requested that The above named party IS NOT found to be in Contempt. A. The above named party has intentionally and without legal justification failed to comply B. with a court order and IS found in Contempt for failure to: . per Pay child support in the amount of $ 1. . per Pay maintenance (spousal support) in the amount of $ 2. . per Pay family support in the amount of $ 3. . Pay uninsured medical bills in the total amount of $ 4. Return property that was awarded to the other party. 5. Sign/complete final documentation (Quit Claim Deed, QDRO, WI Real Estate 6. Transfer Return, vehicle titles, etc.). Pay debts that he/she was ordered to pay. 7. to equalize the property settlement. Pay the amount of $ 8. Allow the other party to claim the children as tax exemptions as ordered. 9. Provide medical insurance cards and/or other medical records. 10. Pay transportation expenses related to placement in the total amount of $ 11. Other: 12. Other: 13. 2. Remedial Sanctions (requirements to force compliance with a court order) No Remedial Sanctions are ordered. A. The party named in #1 above is ordered arrested and committed to the County jail B. days. for With Huber (Work Release) Privileges. 1. Without Huber (Work Release) Privileges. 2. Other Sanctions as follows: C. D. Effective Date: The Remedial Sanction in B & C above is: . Made effective immediately 1. Stayed (delayed) until 2. At which time the party shall report to the County Jail if not in full compliance. 3. Purge Terms: The party is given the ability to purge (get rid of) the contempt by: No purge terms are ordered. A. Paying $ B. In a one time payment by the following date 1. Per month beginning 2. (date) a. All arrears balances are paid in full. b. Other: c. Other as follows: C. until See attached 4. Payments shall be made: No payments are ordered to be made. A. to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee, B. Wisconsin 53274-0200. Directly from the payer to WI SCTF (only allowable if self-employed). 1. By income assignment from the payer’s employer as indicated below: 2. Employer name: Address of payroll office: Zip: State: City: Fax: Phone: FA-4176V, 01/08 Decision & Order for Contempt §767.78 Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Decision & Order for Contempt 5. Page 3 of 3 Case No. ____________ Other order(s): Enter other orders made by the court. See attached Check A or B. If B, enter the date and time of the review hearing, the judge who will preside, and the room number where 6. A future hearing is NOT required. A. is set for (date) B. before time in Room # am/pm . 7. Both parties shall notify the Clerk of Courts and the local Child Support Agency in writing, within 10 business days of any change of address, employment, and of any substantial change in income affecting the ability to pay support. This notification does not change the support order. Any party may file moving papers to change this order. 8. If this matter was heard by a Court Commissioner, and either party requests a new hearing, a Request for New (DeNovo) Hearing must be filed with the Clerk of Court’s within the time period established by local court rule. 9. If this matter was heard by a Circuit Court Judge, this is a final judgment/order for purposes of appeal. FAILURE TO OBEY THIS ORDER IS PUNISHABLE AS CONTEMPT OF COURT AND MAY RESULT IN A JAIL SENTENCE. BY THE COURT: Signature of Circuit Court Judge/Court Commissioner Name Printed or Typed For Court Use Only Date RATIFICATION AND CONFIRMATION This Order of the Court Commissioner is ratified and confirmed as an Order of the Circuit Court. BY THE COURT: Signature of Circuit Court Judge Name Printed or Typed For Court Use Only Date When you submit this order to the court, you must send copies to the other parties. The other party has up to 5 business days to object to the accuracy of this order. FA-4176V, 01/08 Decision & Order for Contempt §767.78 Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com PRINT in BLACK ink Enter the name of the county in which this case is filed. This form is used for divorce, legal separation and paternity cases. Some information may not apply to your case. For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY INCOME & EXPENSE STATEMENT Enter the case number and child support IV-D KIDS number, if known. Case No. IV-D KIDS Case No. Failure by either party to complete and file this form as required will authorize the court to accept the statement of the other party as the basis for its decisions. Deliberate failure to provide complete disclosure is a crime. Attach additional pages if space is not sufficient. 1. PROOF OF INCOME Attach a statement reflecting income earned to date for the current year. Attach most recent W-2 Statement.     2. GENERAL INFORMATION Name Address Address City Phone (day) Zip State 3. CURRENT MEMBERS OF YOUR HOUSEHOLD Enter the name and relationship of all people actually living in your household at this time. Check yes or no to identify if they contribute to payment of household expenses.  5¡  ¦£4  ¦  # 2 3 ¦ ¥¦ ¥¢©0©)(©"'¦ % $ 1 #  # ¦ !   & #  ! #  !" ©©¨  ¢ ¦ ¦ ¤ ¢ §¥£¡ I live alone 7 A 7 @ 7 9 7 86 4. MONTHLY INCOME Income from wages / salary is received (check one): To calculate monthly gross income use the multiplier shown: every other week (bi-weekly) -multiply bi-weekly income by 2.15 weekly -multiply weekly income by 4.3 twice a month-multiply semi-monthly income by 2 monthly MONTHLY GROSS INCOME 1. Gross monthly income (before taxes and deductions) from salary and wages, including commissions, allowances and overtime. Pensions, retirement funds and social security benefits received Disability, Unemployment Insurance and/or public assistance funds received Interest and Dividends received 7. Child Support and maintenance (spousal support) received Rental payments received (from property you rent to others) Bonuses received Other sources of income received: (please specify) Total Gross Income (add lines 1-9) 86 7 I 8G H 7 F 7 E 7 D 7 C 7 B 7 A 7 @ 7 9 FA-4138 Pro Se, 01/07 Income and Expense Statement §§767.127 and 946.32(1)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. Page 1 of 2 www.FormsWorkflow.com MONTHLY DEDUCTIONS 11. Number of tax exemptions claimed 12. Monthly federal and state income tax, Social Security, and Medicare withholdings 13. Medical insurance 14. Other insurance (Life, disability, etc.) 15. Union or other dues 16. Retirement, pension and/or deferred compensation fund 17. Child support or spousal support payment deductions 18. Other deductions: (please specify) 19. 20. 21. Total Monthly Deductions (add lines 12 – 20) MONTHLY NET INCOME (subtract line 21 from line 10) 5. CURRENT MONTHLY HOUSEHOLD EXPENSES Monthly Household Expenses 1. Rent/mortgage payment/property taxes/home or rent insurance (primary residence) 2. Food 3. Utilities (electricity, heat, water, sewage, trash) 4. Telephone (local, long distance & cellular) 5. Cable/Satellite and Internet Services 6. Insurance (life, health, accident, auto, liability, disability, excluding insurance that is paid through payroll deductions) 7. Auto payments (loans/leases), auto expenses (gas, oil, repairs, maintenance), and transportation (other than automobile) 8. Medical, dental and prescription drug expenses (not covered by insurance) 9. Childcare (babysitting and day care) 10. 11. Child support or spousal support payments (Exclude payments made through payroll deductions) Other expenses Other Monthly installment payments: 12. Mortgage (other than primary mortgage) 13. Other vehicle payments (RV, boat, ATV) 14. Credit card debt (total minimum monthly payments) 15. Court ordered obligations 16. Student loans 17. Other personal loans 18. TOTAL MONTHLY EXPENSES (Add lines 1-18) do not have assets ( do 6. I fair market value of $10,000 or more at this time. with a total Xf3afUh8iXX3d)U3v3Qcb f8QcaRt8fa`rfec3U8icU83U8ac3h3f3fa3833ca3Q XV U3RP x Ve Q ` Ye p w V V e p Q u Te b ` Y s V ie Y q b Q g b g W d p i Yb Q g ` Qe de Y Q W d Qb ` Y W T S Q 7. DECLARATION: I declare under penalty of perjury that the above, including all attachments, is true and correct as of the date signed below. Sign and print your name. Enter the date on which you signed your name. Signature Print or Type Name Note: This signature does not need to be notarized. Date FA-4138 Pro Se, 01/07 Income and Expense Statement §§767.127 and 946.32(1)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com PRINT in BLACK ink Enter the name of the county in which this case is filed. This form is used for divorce, legal separation and paternity cases. Some information may not apply to your case. For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY INCOME & EXPENSE STATEMENT Enter the case number and child support IV-D KIDS number, if known. Case No. IV-D KIDS Case No. Failure by either party to complete and file this form as required will authorize the court to accept the statement of the other party as the basis for its decisions. Deliberate failure to provide complete disclosure is a crime. Attach additional pages if space is not sufficient. 1. PROOF OF INCOME Attach a statement reflecting income earned to date for the current year. Attach most recent W-2 Statement.     2. GENERAL INFORMATION Name Address Address City Phone (day) Zip State 3. CURRENT MEMBERS OF YOUR HOUSEHOLD Enter the name and relationship of all people actually living in your household at this time. Check yes or no to identify if they contribute to payment of household expenses.  5¡  ¦£4  ¦  # 2 3 ¦ ¥¦ ¥¢©0©)(©"'¦ % $ 1 #  # ¦ !   & #  ! #  !" ©©¨  ¢ ¦ ¦ ¤ ¢ §¥£¡ I live alone 7 A 7 @ 7 9 7 86 4. MONTHLY INCOME Income from wages / salary is received (check one): To calculate monthly gross income use the multiplier shown: every other week (bi-weekly) -multiply bi-weekly income by 2.15 weekly -multiply weekly income by 4.3 twice a month-multiply semi-monthly income by 2 monthly MONTHLY GROSS INCOME 1. Gross monthly income (before taxes and deductions) from salary and wages, including commissions, allowances and overtime. Pensions, retirement funds and social security benefits received Disability, Unemployment Insurance and/or public assistance funds received Interest and Dividends received 7. Child Support and maintenance (spousal support) received Rental payments received (from property you rent to others) Bonuses received Other sources of income received: (please specify) Total Gross Income (add lines 1-9) 86 7 I 8G H 7 F 7 E 7 D 7 C 7 B 7 A 7 @ 7 9 FA-4138 Pro Se, 01/07 Income and Expense Statement §§767.127 and 946.32(1)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. Page 1 of 2 www.FormsWorkflow.com MONTHLY DEDUCTIONS 11. Number of tax exemptions claimed 12. Monthly federal and state income tax, Social Security, and Medicare withholdings 13. Medical insurance 14. Other insurance (Life, disability, etc.) 15. Union or other dues 16. Retirement, pension and/or deferred compensation fund 17. Child support or spousal support payment deductions 18. Other deductions: (please specify) 19. 20. 21. Total Monthly Deductions (add lines 12 – 20) MONTHLY NET INCOME (subtract line 21 from line 10) 5. CURRENT MONTHLY HOUSEHOLD EXPENSES Monthly Household Expenses 1. Rent/mortgage payment/property taxes/home or rent insurance (primary residence) 2. Food 3. Utilities (electricity, heat, water, sewage, trash) 4. Telephone (local, long distance & cellular) 5. Cable/Satellite and Internet Services 6. Insurance (life, health, accident, auto, liability, disability, excluding insurance that is paid through payroll deductions) 7. Auto payments (loans/leases), auto expenses (gas, oil, repairs, maintenance), and transportation (other than automobile) 8. Medical, dental and prescription drug expenses (not covered by insurance) 9. Childcare (babysitting and day care) 10. 11. Child support or spousal support payments (Exclude payments made through payroll deductions) Other expenses Other Monthly installment payments: 12. Mortgage (other than primary mortgage) 13. Other vehicle payments (RV, boat, ATV) 14. Credit card debt (total minimum monthly payments) 15. Court ordered obligations 16. Student loans 17. Other personal loans 18. TOTAL MONTHLY EXPENSES (Add lines 1-18) do not have assets ( do 6. I fair market value of $10,000 or more at this time. with a total Xf3afUh8iXX3d)U3v3Qcb f8QcaRt8fa`rfec3U8icU83U8ac3h3f3fa3833ca3Q XV U3RP x Ve Q ` Ye p w V V e p Q u Te b ` Y s V ie Y q b Q g b g W d p i Yb Q g ` Qe de Y Q W d Qb ` Y W T S Q 7. DECLARATION: I declare under penalty of perjury that the above, including all attachments, is true and correct as of the date signed below. Sign and print your name. Enter the date on which you signed your name. Signature Print or Type Name Note: This signature does not need to be notarized. Date FA-4138 Pro Se, 01/07 Income and Expense Statement §§767.127 and 946.32(1)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com