FORM SUMMARY Name of Form: Stipulation for Temporary Order Without Minor Children Form Number: FA-4127V Statutory Reference: §§767.225 and 767.34, Wisconsin Statutes Benchbook Reference: Purpose of Form: This document allows the parties in an action for a divorce or legal separation without minor children to agree on how various issues such as asset allocation, debt payments, maintenance payments, and similar matters will be handled while the action is pending. Who Completes It: The parties would fill out the document, checking boxes and writing in the information as they have agreed. Distribution of Form: Original will be filed with the court. Copies would generally be retained by both of the parties and Family Court Commissioner. 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: Add "directly to the wife/husband" in the Medical Ins. and Payments sec. In Personal Property Division, add "that is yet to be exchange". Comments: This form should not be used if the parties have minor children. Form FA-4126, Stipulation for Temporary Order with Minor Children, should be used instead. This form is very inclusive and may include provisions that are not relevant to a particular situation. If a provision is not relevant, it should be marked accordingly. 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 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 and Enter the name of the respondent. If joint petitioners, enter the name of the husband. Stipulation for Temporary Order Respondent/Joint Petitioner-Husband: Without Minor Children First name Middle name Last name Divorce-40101 Legal Separation-40201 Check divorce or legal separation. Note: Enter the case number, if known. If not leave blank. Case No. SUMMARY OF PERSONAL INFORMATION Enter the requested information about the wife. Include area codes with the requested phone numbers. Dates of birth should be written in the following format: [month, day, year]. Enter the requested information about the husband. Include area codes with the requested phone numbers. Dates of birth should be written in the following format: [month, day, year]. 1. Wife: Name Address Address City Date of birth Gross monthly income $ Employer name Address of payroll office City Phone Zip State Zip State Fax 2. Husband: Name Address Address City Date of birth Gross monthly income $ Employer name Address of payroll office City Phone Zip State Zip State Fax FA-4127V, 01/08 Stipulation for Temporary Order – Without Minor Children §§767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 6 American LegalNet, Inc. www.FormsWorkflow.com Stipulation for Temporary Order – Without Minor Children Page 2 of 6 Case No. ______________ STIPULATION The parties agree that the following terms be in effect until the final hearing of this action. For A1, check a or b. If b, enter the monthly amount of maintenance and the month and year on which the payments will begin. For A2, check a or b. If b, enter the monthly amount of maintenance and the month and year on which the payments will begin. Check 1, 2, or 3. Parties may not make payments directly to each other. (See WI Stat. 767.265) 1. SUMMARY OF FINANCIAL AGREEMENTS A. Maintenance (spousal support) The parties agree that temporary maintenance shall be paid as follows: 1. For the Wife: The wife gives up her right to receive maintenance at this time. a. The husband shall pay maintenance to the wife in the amount of $ b. . 20 per month beginning on the first day of the month of 2. For the Husband: The husband gives up his right to receive maintenance at this time. a. The wife shall pay maintenance to the husband in the amount of $ b. . 20 per month beginning on the first day of the month of B. Payments for Maintenance shall be made to the Wisconsin Support Collections Trust Fund (WI SCTF): Directly from the payer to WI SCTF (only if self-employed). 1. By income assignment from the payer’s employer as indicated on page 1. 2. No maintenance is to be paid at this time. 3. C. Information about how payments are made to WI SCTF. All payments for maintenance ordered shall note the case number and the names of the parties on the face of the check, should be made payable to WI SCTF, and sent to: Wisconsin Support Collections Trust Fund Box 74400 Milwaukee, WI 53284-0400 The WI SCTF will transmit the payments to the proper persons entitled to them. Failure of an employer to pay the proper amount shall not be a defense for failure to pay the proper amount. If an employer fails to take out the correct amount for maintenance, the party paying is responsible for the full and correct amount. The party paying maintenance is responsible for payment of the annual receiving and disbursing fee to WI SCTF. 2. SUMMARY OF OTHER AGREEMENTS Check 1 or 2. If 2, check a, b, c or d. If a , b or d enter the date [month, day, year]. For 3, check a, b, or c. If c, enter the date. For 4, check a or b. If a, attach the agreed upon arrangements. A. Residence: The parties do not own or rent a residence together. 1. The parties do own or rent a residence together and agree that: 2. The wife shall have temporary exclusive use of the residence and the a. husband shall leave the residence on or before The husband shall have temporary exclusive use of the residence and the b. wife shall leave the residence on or before Both parties agree to share the residence. c. Both parties agree to vacate and/or sell the residence by d. 3. Sale of Residence: The parties do not own a residence. a. The residence shall not be placed for sale at this time. b. The residence shall be placed for sale no later than c. 4. Other Real Estate: One or both of the parties own additional real estate, the agreement for temporary use of which is disclosed as an attachment. Yes, see attached agreement. a. No b. FA-4127V, 01/08 Stipulation for Temporary Order – Without Minor Children . . . §§767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 6 American LegalNet, Inc. www.FormsWorkflow.com Stipulation for Temporary Order – Without Minor Children Check 1 or 2. If 2, complete the chart on the right indicating who has and who will have possession while the case is pending. Page 3 of 6 Case No. ______________ B. Personal Property Division: The parties agree that the wife shall be awarded the temporary exclusive use of the personal property in her possession and the husband shall be awarded the temporary exclusive use of the personal property in his possession. with no exceptions. 1. except for the following property: 2. Who has possession? List the property that is yet to be exchanged and check if the wife or husband will have temporary use of the property until the divorce/legal separation is final. Wife = W Husband = H Who will have possession? Wife = W Husband = H Household Items H W H Automobiles Year, Make, Model W H W H Securities: Stocks, Bonds, Mutual Funds, Commodity Accounts Name of Company & # of shares W H W H Checking and Savings Accounts Name of Bank or Financial Institution If property needs to be exchanged, enter the date [month, day, year] by which the property shall be exchanged, and describe how it will be exchanged. W W H W H Other Personal Property Description of Asset W H W H Any exchange of property shall be made by (date) according to the following arrangements: FA-4127V, 01/08 Stipulation for Temporary Order – Without Minor Children §§767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 6 American LegalNet, Inc. www.FormsWorkflow.com Stipulation for Temporary Order – Without Minor Children Page 4 of 6 Case No. ______________ C. Debts and Liabilities 1. Each of the parties shall be responsible for the following debts and liabilities: Write the names of the creditors to whom the parties owe money. Then check the box to indicate who will temporarily make the minimum monthly payment to each creditor. Payment for: Mortgage Rent Car 1 Car 2 Insurance-Home Insurance-Auto Insurance-Medical Insurance-Life Loans-Student Loans-Personal Loans-Other Credit Card 1 Credit Card 2 Credit Card 3 Credit Card 4 Other Other Other Payment to: Paid by Paid by husband wife Shared equally 2. The parties agree and understand: • Unless otherwise agreed upon in the order, each party shall pay his or her own future monthly household expenses. • Each party assigned a debt shall be fully responsible for that obligation and shall not make any demands upon the other party concerning that debt. • Both parties are restrained from making any further debts against the credit of the other party. • Any debt incurred after the date of this order shall be the responsibility of the party who incurred it and that party shall not make any demands upon the other party concerning that debt. • Creditors are NOT bound by this agreement and that each party remains liable to creditors for all marital debts. • Any party who suffers a loss because of a failure of the other party to pay an assigned debt may enforce that obligation by an order to show cause for contempt of court. D. Incorporation of Agreement Into Temporary Order The parties agree that this stipulation shall be submitted to the court for approval and all parties request that the court make this stipulation a temporary order of the court. E. The parties agree that: This court has jurisdiction over the marriage and the parties individually. Both parties freely and voluntarily, without any force or coercion, enter into and sign this agreement.     FA-4127V, 01/08 Stipulation for Temporary Order – Without Minor Children §§767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 6 American LegalNet, Inc. www.FormsWorkflow.com Stipulation for Temporary Order – Without Minor Children Page 5 of 6 Case No. ______________ Both parties have fully disclosed all information about income, expenses, assets and debts to each other. This agreement is based on compromise between the parties, but as a whole, is fair and reasonable. A court may enforce the terms of this agreement through the powers of contempt of court.       The wife must sign and print her name. Signature of Wife Enter the date on which she signed her name. Print or Type Name Note: This signature does not need to be notarized. The husband must sign and print his name. Date Signature of Husband Enter the date on which he signed his name. Print or Type Name Note: This signature does not need to be notarized. Date TEMPORARY ORDER 1. The agreement of the parties as set out in this stipulation is adopted by the court. 2. The parties are ordered to comply with this agreement while this divorce/legal separation action is pending unless this order is changed by a later court order. 3. The court further orders: A. Income Tax Returns. The parties agree to file their income tax returns consistent with the rules of the IRS, Wisconsin Department of Revenue, and Wisconsin’s Community Property law. B. Modification and Waiver. A modification or waiver of any of the provisions of this agreement shall be effective only if it is made in writing and is dated and signed by all parties and approved by the court. C. Restraining Order. Both parties are restrained from interfering with the personal liberty of the other, from encumbering or disposing of assets or property, and from incurring debts or credit in the name of the other party. D. Change of Employer/Address. Both parties shall notify the Clerk of Courts and the county Child Support Agency within 10 days of any change of address or change of employers. Notice shall also be sent at the same time to the other spouse unless contact is prohibited by court order. E. Failure to abide by these temporary orders is punishable as contempt of court pursuant to ch. 785 Wis. Stats. All temporary orders are made without prejudice to the rights of either party at the time of the final hearing. F. Both parties are prohibited from encumbering, concealing, damaging, destroying, transferring, selling, giving away, or removing from this state any of his, her or their property without permission of the court, or written consent of both parties, except in the usual course of business, or in order to secure necessities. FA-4127V, 01/08 Stipulation for Temporary Order – Without Minor Children §§767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 5 of 6 American LegalNet, Inc. www.FormsWorkflow.com Stipulation for Temporary Order – Without Minor Children Page 6 of 6 Case No. ______________ G. Neither party can disconnect any utility services or cause any other essential services of the residence of the other party to be discontinued without written consent of the parties or further order of the court. H. Each party is responsible for his or her own future uninsured medical, dental, orthodontic, hospital, psychiatric, counseling, drug and other health expenses. I. Both parties shall maintain all current beneficiaries on all life, medical, hospital, automobile, household, or other insurance and in any current wills while this action is pending. J. Pursuant to § 767.75(a) Wis. Stats., this temporary order for maintenance constitutes an assignment of all commissions, earnings, salaries, wages, pension benefits, benefits under ch. 102 or 108 Wis. Stats., and other money due or to be due in the future to the Wisconsin Support Collections Trust Fund as will be sufficient to meet the maintenance ordered here. K. Pursuant to § 767.75(2r) Wis. Stats., if maintenance is to be paid, the assignment of paragraph “j” above is effective immediately, and the employer of the party paying shall be notified of the assignment of income immediately. 4. Failure to comply with the terms of this order may result in punishment for contempt of court under ch. 785 Wis. Stats. BY THE COURT: For Court Use Only Circuit Court Judge/Circuit Court Commissioner Print or Type Name Date FA-4127V, 01/08 Stipulation for Temporary Order – Without Minor Children §§767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 6 of 6 American LegalNet, Inc. www.FormsWorkflow.com