FA-4175V, 02/19 Decision &and Order on Motion or Order to Show Cause to Change: Legal Custody/ 247247767.451 and 767.59, Wisconsin Statutes Physical Custody/Child Support/Maintenance/Arrears Payment/Other This form shall not be modified. It may be supplemented with additional material. Page 1 of 5 Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: Enter the name of the county in which the original case was filed. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Check marriage or paternity. If paternity, enter initials of child. IN RE: THE MARRIAGE PATERNITY OF Decision and Order on Motion or Order to Show Cause to Change Legal Custody Physical Placement Child Support Maintenance Arrears Payment Other: Case No. Enter the name, address, and daytime phone number of the petitioner or joint petitioner A from the original case file. Petitioner/Joint Petitioner A Name (First, Middle and Last) Current Mailing Address City State Zip Daytime phone number -vs- On the far right, mark the box for the change(s) you requested and enter the original case number. Enter the name, address, and daytime phone number of the respondent or joint petitioner B from the original case file. Respondent/Joint Petitioner B Name (First, Middle and Last) Current Mailing Address City State Zip Daytime phone nu mber Check if the State of Wisconsin is a party or not. If you are unsure, you may call your local Child Support Agency. The State of Wisconsin (Child Support Agency) is is not a party to this action. STOP! Do not complete the remainder of this form unless required by the court official who is hearing this case. HEARING Enter the name of the court official who held the hearing and the address and date [month, day, year] on which it was held. A hearing was conducted in this matter as follows: 1. Before Circuit Court Judge/Circuit Court Commissioner 2. Location 3. Date Time a.m. p.m. American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-4175V, 02/19 Decision and Order on Motion or Order to Show Cause to Change: Legal Custody/ 247247767.451 and 767.59, Wisconsin Statutes Physical Custody/Child Support/Maintenance/Arrears Payment/Other This form shall not be modified, It may be supplemented with additional material. Page 2 of 5 APPEARANCES Check one box from 1 and check A or B. If B, enter the name of the attorney. 1. Former Petitioner/Joint Petitioner A appeared in person appeared by phone did not appear AND A. was self-represented. B. was represented by Attorney . Check one box from 2 and check A or B. If B, enter the name of the attorney. 2. Former Respondent/Joint Petitioner B appeared in person appeared by phone did not appear AND A. was self-represented. B. was represented by Attorney . In 3, check A, B, C, or D. If B, C, or D, enter the name of the individual who appeared. 3. Others appearing at the hearing: A. None. B. Child Support Agency by . C. Guardian ad Litem (GAL) . D. Other: . FINDINGS and ORDER Based on the findings and reasons stated, IT IS ORDERED: In 1, check A, B, or C. Check A if the court denied the request to change the order. Check B if the judge ordered the parties to do certain things before he/she makes a decision. If B, check all that apply and complete the corresponding information as necessary. 1. The Motion or Order to Show Cause is A. DENIED because no substantial change in circumstance was found. The current order remains in effect. B. DEFERRED to collect more information. Before making a final decision the court orders the following: 1) The parties attend mediation with a. no payment is required. b. Petitioner/Joint Petitioner A to pay $ towards the mediation fee by . c. Respondent/Joint Petitioner B to pay $ towards the mediation fee by . 2) Attorney be appointed as GAL and a. no payment is required. b. Petitioner/Joint Petitioner A pay $ towards the GAL fee by . c. Respondent/Joint Petitioner B to pay $ towards the GAL fee by . 3) A physical placement study be conducted by . a. no payment is required. b. Petitioner/Joint Petitioner A to pay $ towards the study fee by . c. Respondent/Joint Petitioner B to pay $ towards the study fee by . 4) Other : Check C, if the judge ordered changes to the current court order. If 1, enter the children222s names and check all that apply in a-f, and complete the corresponding information as was ordered by the court. C. GRANTED as follows : 1) Physical Placement Order(s) (time with children) for the following minor children: a. from primary physical placement with [Name of Parent] to primary placement with (Name of Parent) b . from shared placement to primary placement with [Name of Parent] c. from primary placement to shared placement. d . from the current shared placement schedule (if any) to a new sha red placement schedule. American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-4175V, 02/19 Decision and Order on Motion or Order to Show Cause to Change: Legal Custody/ 247247767.451 and 767.59, Wisconsin Statutes Physical Custody/Child Support/Maintenance/Arrears Payment/Other This form shall not be modified, It may be supplemented with additional material. Page 3 of 5 The new placement schedule for the changes in a - d above is as follows: See attached e . to require placement with [Name of Parent] be supervised. unsupervised. f. Other: See attached If 2, enter the children222s names and check all that apply in a-c. 2) Legal Custody (decision making) for the following children: a. to joint legal custody with both parents. b. to sole legal custody with [Name of Parent] c. Other: See attached Reasonable cost is defined as the total amount paid for insurance coverage where the cost does not exceed 10% of the insuring parent222s monthly income available for child support. 3) Medical Insurance and Payments . Parents are required to provide private health insurance for their minor child(ren) if service providers are located within 30 miles or 30 minutes from the child222s residence and if the cost is reasonable. Reasonable cost is defined as the difference between single and family coverage where the added cost does not exceed 10% of the insuring parent222s monthly income available for child support. The insuring parent may receive a contribution toward the cost of the insurance from the other parent, either as a credit against the child support obligation or an increase in the non-insuring parent222s child support obligation as long as the increase does not exceed 10% of the non-insuring parent222s gross monthly income. The parties understand that such medical insurance coverage for the minor child(ren) including medical, dental, orthodontic, hospital, psychiatric, counseling, drug and other health expenses which is curre ntly offered shall be provided and paid by Check a, b, c, or d. a . both parties. They shall provide private health insurance and neither parent is required to make a cash contribution to the other. If b, enter who will provide insurance, the out of pocket cost for such insurance, and the amount the other party will contribute. b. shall provide private health insurance. The out of pocket cost (difference between single and family coverage) to cover the child(ren) under such insurance is $ . The other parent shall contribute $ toward that cost (as a reasonable cash contribution) and that amount, if any, is included as a deviation in the child support calculation in 4.b . of Child Support and Financial Expenses below. If c, indicate who will be responsible for providing public health insurance and whether the children are enrolled or need to need to be enrolled. c. A comprehensive private health insurance policy is not available to either parent at a reasonable cost. The Petitioner/Joint Petitioner A Respondent/Joint Petitioner B has enrolled in shall promptly apply for Public Health Insurance. 1. There is no out of pocket expense for the above Public Health Insurance. Also, check 1 or 2. If 2, indicate the cost for such insurance and the amount the other party will contribute, 2. Out of pocket cost for such insurance is $ . The other parent shall contribute $ toward tha