FORM SUMMARY Name of Form: Order To Show Cause and Affidavit to: Change Legal Custody, Physical Placement, Child Support, Maintenance, and/or Other Form Number: FA-4171V Statutory Reference: §§765.105, 767.451 and 767.59, Wisconsin Statutes Benchbook Reference: Purpose of Form: This form may be used to order another party to come to court to justify why the requested change contained within the order should not be granted. Requests to change generally include issues 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 a modification to the custody, placement, child support, maintenance, or other orders; a judge or court commissioner signs the Order itself. Distribution of Form: Original to clerk of court. Depending on the particular county involved, either the original order itself, a duplicate original of the Order or an authenticated copy would be personally served on 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 a Notice and Motion to Modify (FA-4170V) to accomplish the same end. The basic difference between the two is one of service. An order to show cause must be personally served on the other party; a notice can be served by other means. 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 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. For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY marriage In RE: The paternity of Petitioner/Joint Petitioner: First name Middle name Last name Current Mailing Address City State Zip Daytime phone number Order To Show Cause and Affidavit to Change: Legal Custody Physical Placement Child Support Maintenance Other: vs. 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. 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 Case No. is not a party to this action. ORDER TO SHOW CAUSE Upon the attached Affidavit, IT IS ORDERED THAT 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 to show cause (give reasons) why the requests in the attached affidavit should not be granted. If you do not appear as indicated, the court may proceed without you and grant the request. IT IS FURTHER ORDERED: • a copy of this order and affidavit be personally served upon all other parties at least 5 business days before the date of the hearing. • both parties must bring to court their fully completed, dated, and signed Financial Disclosure Statement and all required attachments. BY THE COURT: Circuit Court Judge For Court Use Only. Circuit Court Commissioner Name Printed or Typed Date FA-4171V, 02/10 Order To Show Cause and Affidavit 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 _______________ Order To Show Cause and Affidavit to Change: Custody/Physical Placement/Support/Maintenance Page 2 of 3 Case No. AFFIDAVIT 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: See attached . 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. attempted mediation on (Date) have not attempted mediation for this issue. B. Legal Custody (decision making) for the following children: Check C if you are requesting changes to support orders. 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 cash upward include a deviation of $ B. contribution for health insurance. to per Maintenance (Spousal Support) that is currently $ 2. to be determined by the court , 20 an amount beginning a. 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 the , 20 an amount beginning a. 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. I will be able to provide documentation to the court that supports my request. 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. The other party and I 1. 2. 3. to joint legal custody with both parents. to sole legal custody with (Name of Parent) Other: NOTICE: Both parties must bring to court their fully completed, dated, and signed Financial Disclosure Statement and all required attachments. FA-4171V, 02/10 Order To Show Cause and Affidavit 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 _______________ Order To Show Cause and Affidavit to Change: Custody/Physical Placement/Support/Maintenance Page 3 of 3 Case No. D. Other change(s): In D, enter any other changes you may have. 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-I. 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. See attached . 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, or B. 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 I owe maintenance has remarried. H. Other: I. 4. The facts explaining the substantial change in circumstances or deviation in child support percentage standard are: In 4, describe the facts that justify the change you want. Attach additional pages, if necessary. 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 scheduled call: court date. Please note that the court does not provide transportation. 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 Have the Notary Public sign, date, and seal the document. State of County of Subscribed and sworn to before me on (Seal) Notary Public/Court Official My commission/term 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 the Service Packet for more information. FA-4171V, 02/10 Order To Show Cause and Affidavit 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