FORM SUMMARY Name of Form: Order to Show Cause and Affidavit for Temporary Order With Minor Children Form Number: FA-4128V Statutory Reference: §§767.117, 767.127, and 767.225, Wisconsin Statutes Benchbook Reference: Purpose of Form: This form allows a party in an action for divorce or legal separation in which there are minor children to request a hearing before the court to have an order entered that would resolve various issues such as asset allocation, debt payments, child custody and support, maintenance payments, and similar matters while the case is pending. It would be used when the parties are unable to reach an agreement on such issues. Who Completes It: The party seeking the hearing would complete the caption and sign the affidavit section on page 3. After signing the affidavit, the signor would seek out a notary public, be sworn, and sign the affidavit under oath. The notary public would complete the notarial section. The party would then take the document to the court to have the court complete the date, time, place of the hearing and the name of the presiding court official. Distribution of Form: Original will be filed with the court. Authenticated copy would be served on the other party. Accompanying Forms: Although none are necessarily required, there may be schedules attached listing property, debts, or other information that doesn’t fit on the form. Financial disclosure statements may also be attached as needed. New Form/Modification: Modification; last update 10/06. Modification: Added more descriptive instructions and lines after "other specific relief I believe appropriate as follows:" and further ordered statement regarding completion of FDS. Comments: None 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. Date: 01/17/2008 Page 1 American LegalNet, Inc. www.FormsWorkflow.com PRINT in BLACK ink Enter the name of the county in which you are filing this case. Enter the name and address of the petitioner. If joint petitioners, enter the name of the wife. For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY In RE: The marriage of: Petitioner/Joint Petitioner-Wife: First name Middle name Last name Order to Show Cause and Affidavit for Temporary Order Address Address With Minor Children City Enter the name and address of the respondent. If joint petitioners, enter the name of the husband. Check divorce or legal separation. State Zip and Respondent/Joint Petitioner-Husband: First name Middle name Divorce-40101 Legal Separation-40201 Case No. Last name Address Address Enter the case number, if known. If unknown, leave blank. City State Zip ORDER TO SHOW CAUSE Based on the attached Affidavit and Request for Hearing for Temporary Order, IT IS ORDERED that the parties Show Cause, In Person: Before: Circuit Court Judge or Circuit Court Commissioner For Court Use Only: The clerk will complete this section. Location: Date: Time: a.m./p.m. or as soon as the matter may be heard, why a temporary order should not be entered for the relief requested in the attached affidavit. PENDING FURTHER COURT ORDER or written stipulation of the parties, neither party shall engage in any activity that negatively affects the health, safety or welfare of either party or minor children including but not limited to: FA-4128V, 04/08 Order to Show Cause and Affidavit for Temporary Order-With Minor Children §§767.117, 767.225 and 767.127, 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 for Temporary Order-With Minor Children Page 2 of 3 Case No. _______________ Both parties are restrained from harassing, intimidating, physically abusing, or imposing any restraint on the personal liberty of the other party, the other party’s employer, or the minor children of the parties.   Both parties are prohibited from going upon the premises occupied by the other as a residence, except for purposes of a change in the physical placement of the minor children.   Both parties are restrained from concealing the minor children of the parties from the other party and from removing the minor children from the state of Wisconsin during periods of physical placement for longer than 96 hours, without permission of the court or written consent of both parties.   Both parties are restrained from making any further debts against the credit of the other party. Further, unless otherwise ordered, any debt incurred after the date of this order is the sole responsibility of the party incurring the debt.   Both parties are restrained from disconnecting any utility service or causing any other essential services of the residence of either party to be disconnected. Both parties shall maintain all current beneficiaries on all life, medical, hospital, automobile, household or other insurances and in any current wills while this action is pending.     IT IS FURTHER ORDERED that both parties bring to this hearing a completed Financial Disclosure Statement. Check your spouse and check the State if you are currently receiving public assistance. Check other if there is another party(s) to the action, and enter the party’s name(s). IT IS FURTHER ORDERED that a copy of this order, together with the supporting papers, be served in person at least 5 business days before the time of this hearing, upon the: Wife Husband State of Wisconsin through the county child support agency Other: Failure to appear as ordered may result in the issuance of a warrant directing the Sheriff to arrest you and bring you to court. Failure to appear will not stop the court from proceeding with the hearing and making the orders requested by your spouse. Parties are encouraged to arrive early and determine if any issues can be resolved before the hearing. BY THE COURT: For Court Use Only Circuit Court Judge/Circuit Court Commissioner Print or Type Name Date FA-4128V, 04/08 Order to Show Cause and Affidavit for Temporary Order-With Minor Children §§767.117, 767.225 and 767.127, 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 for Temporary Order-With Minor Children Page 3 of 3 Case No. _______________ AFFIDAVIT 1. My spouse and I have not agreed on a temporary arrangement while this action is pending, and there is a need for such an order. 2. I request that a hearing be held concerning one or more of the following issues: List any additional disputed matters you need resolved at the temporary hearing. • • • • • • • • Legal custody and physical placement Child support Maintenance Use of the residence and other property Payment of debts and financial obligations Payment of insurance and health care expenses Other relief the court believes appropriate Other specific relief I believe appropriate as follows: See attached 3. I request a hearing be held and a temporary order be entered pursuant to §767.23(1), Wis. Stats. 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 Have the Notary Public sign, date, and seal the document. Subscribed and sworn to before me on Notary Public, State of Wisconsin My commission expires: FA-4128V, 04/08 Order to Show Cause and Affidavit for Temporary Order-With Minor Children §§767.117, 767.225 and 767.127, 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