FORM SUMMARY Name of Form: Notice of Motion and Motion to: (Change Legal Custody, Physical Placement, Child Support, Maintenance, and/or Other) Form Number: FA-4170V Statutory Reference: §§767.105, 767.451 and 767.59, Wisconsin Statutes Benchbook Reference: Purpose of Form: This form may be used to give notice to another party that a request is being made and a hearing will be held to change a current order concerning legal custody, physical placement, or child support of a minor child, as well as to change maintenance or any other aspect of a court order. Who Completes It: Party seeking the change in the current order. Distribution of Form: Original to Clerk of Court, Copies for service on all of the other parties. Accompanying Forms: Generally the form may be the only document needed. However if the form’s instructions indicate a supporting document is needed (such as placement schedules or additional documentation), those document(s) should be attached. New Form/Modification: Modification; last update 01/09. Modification: New rule which took effect Jan. 1, 2010 to DCF 150, the Percentage of Income Standard which creates requirements for establishing medical support orders. Under the new rules, a parent who has insurance coverage available that means certain defined criteria must carry that coverage and the other parent may be ordered to contribute to the cost of that coverage. That contribution would be in the form of an upward or downward deviation in the child support amount dependent on which parent is the court ordered payee. Comments: 1. The party seeking the change could alternatively use an Order to Show Cause (FA-4171) to accomplish the same end. The basic differences between the two are who signs it and how is service made on the other party. An order to show cause must be signed by a court official while the notice and motion may be signed by the party. An order to show cause must be personally served on the other party; a notice can be served by other means as well. The reason there are two forms is that the statutes provide that the request can be brought either by “motion” or “order to show cause.” 2. If the parties can stipulate or agree to a change in the type of matters covered by this motion, the parties may use FA-604 to do so without the need for a hearing. About this Form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court’s Office. As a pro se form, its use is NOT mandatory but it is required to be accepted and distributed by the circuit courts of the State of Wisconsin. Approval Date: 02/11/2010 Release Date: 09/20/2010 Posted Date: 09/22/2010 Page 1 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. On the far right, mark the box for the change(s) you are requesting and enter the original case number. 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. 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 City State Zip Daytime Phone Number vs. Notice of Motion and Motion to Change: Respondent/Joint Petitioner: First name Middle name Legal Custody Physical Placement Child Support Maintenance Other: 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. NOTICE OF MOTION Enter the name of the person to whom this motion is directed. TO You are notified that at the following date and time: Before For Court Use Only: This section will be completed by the court. Location Date a.m./p.m. , or as soon as the matter may be heard. Time I will be asking the court to change the existing order in this case as indicated below. If you object to this motion, you need to appear and say so. Otherwise, the court may proceed without you and grant the request. You may contact the Circuit Court Commissioner for more information on modifying and enforcing court orders or judgments. FA-4170V, 02/10 Notice of Motion and Motion to Change: Custody/Physical Placement/Support/Maintenance §§767.105, 767.451, and 767.59, 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 Notice of Motion and Motion to Change: Custody/Physical Placement/Support/Maintenance Page 2 of 3 Case No. __________ MOTION Check A if you are requesting a change to physical placement, list the children affected, check 1-4 and/or 5 and/or 6 and complete the necessary information. Indicate if you have or have not attempted Mediation. If you have, indicate the date of the Mediation session. 1. Modify as follows: A. Physical Placement Order(s) (time with children) for the following children: from primary physical placement with (Name of Parent) to primary placement with (Name of Parent) from shared placement to primary placement with (Name of Parent) 2. from primary placement to shared placement. 3. from the current shared placement schedule (if any) to a new shared placement 4. schedule. The requested placement schedule for the changes in 1-4 above is as follows: 1. See attached 5. 6. to require placement with (Name of Parent) unsupervised. supervised. be Other: The other party and I Check B if you are requesting a change to legal custody, list the children affected, check 1, 2, or 3 and complete the necessary information. Check C if you are requesting changes to support orders. Check 1 if you are requesting changes to child support, enter the amount and frequency of the current payment and check whether it includes a deviation for health insurance. In b, check 1, 2, or 3. Check A or B, indicate deviation information. Check all that apply in 24, and complete all relevant information for each section checked. attempted mediation on (Date) have not attempted mediation for this issue. See attached . B. Legal Custody (decision making) for the following children: 1. 2. 3. to joint legal custody with both parents. to sole legal custody with (Name of Parent) Other: See attached C. Change the following support orders as follows: Child support 1. that per a. that is currently $ does not include a deviation for health insurance or any other reason. 1. downward for upward does include a deviation of $ 2. health insurance. to be paid by (Parent) b. To a new amount beginning to (Parent) based on state child support standards determined by the court. 1. . per a new set amount of $ 2. held open (no payment). 3. I request that this new amount not include a deviation for health insurance or any other reason. A. downward as a upward include a deviation of $ B. cash contribution for health insurance. to per Maintenance (Spousal Support) that is currently $ 2. to be determined by , 20 an amount beginning a. the court based on current income. . , 20 beginning per a new set amount of $ b. to per Arrears payment that is currently $ 3. to be determined by , 20 an amount beginning a. the court. . , 20 beginning per a new set amount of $ b. Arrears balance as it is currently reflected in the WI SCTF KIDS computer 4. because to $ system as $ I have made support or other payments directly to the other party. a. I dispute the amount that is currently on record. b. FA-4170V, 02/10 Notice of Motion and Motion to Change: Custody/Physical Placement/Support/Maintenance §§767.105, 767.451, and 767.59, 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 Notice of Motion and Motion to Change: Custody/Physical Placement/Support/Maintenance Page 3 of 3 Case No. __________ I will be able to provide documentation to the court that supports my request. NOTICE: Both parties must bring to court their fully completed, dated, and signed Financial Disclosure Statement and all required attachments. In D, enter any other changes you may have. D. Other change(s): See attached In 2, enter the date the current court order or judgment was signed by a court official. In 3, check all that apply in A-H. If E or F, enter the party’s information that has changed. If other, enter the change in circumstance that has prompted you to bring this Motion. In 4, describe the facts that justify the change you want. Attach additional pages, if necessary. . 2. The court order that I am asking to be modified was dated 3. This request is based on the following substantial change in circumstances that have occurred since the entry of the prior court order in this case. A child who was living with the other parent is now living with me. A. A child is no longer eligible for child support because the child has reached age 18, B. or is over 18 but under 19, and is no longer pursuing a course of education leading to a high school diploma or its equivalent. One of the parties has or will be moving to a different residence. C. There is not a placement schedule and the parties cannot agree. D. has changed. Employment or work shift of E. both parties has changed. has changed. Income or wages of F. both parties has changed. The availability or cost of health insurance has changed. G. The party to whom maintenance is owed has remarried. H. Other: I. 4. The facts explaining the substantial change in circumstances or deviation in child support percentage standard are: See attached If you require reasonable accommodations due to a disability to participate in the court process, please at least ten (10) working days prior to the call: scheduled court date. Please note that the court does not provide transportation. Sign and print your name. Signature Enter the date on which you signed your name. Print or Type Name NOTE: This signature does not need to be notarized. Date A copy of this Notice of Motion and Motion must be served upon all other parties at least 5 business days before the date of the hearing. If service is by mail, it must be mailed at least 8 business days before the date of the hearing. See the Service Packet for more information. FA-4170V, 02/10 Notice of Motion and Motion to Change: Custody/Physical Placement/Support/Maintenance §§767.105, 767.451, and 767.59, 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