FA-612, 05/17 Interim Financial Summary to Child Support Agency 247767.57(1)(b), Wisconsin Statutes; 45 CFR 302.51 This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Petitioner /Joint Petitioner A Respondent /Joint Petitioner B Amended Interim Financial Summary to Child Support Agency Case No. IV - D Case No. (s): Hearing Date: Name: Birth Date: Address: Street City State Zip Respondent Name: Birth Date: Address: Street City State Zip Child(ren): (Provide Name and Birth Date) Birth date Birth Date Person who will RECEIVE payments: (C heck one) Petitioner/ Joint Petitioner A Respondent / Joint Petitioner B Other: Payments received by WI to be sent to other state : (S pecify) Person who will MAKE payments: (Check one) Petitioner/ Joint Petitioner A Respondent / Joint Petitioner B Phone: Address: Fax: Street City State Zip By income assignment Payor to send payment s to: WI SCTF, Box 74200, Milwaukee, WI 53274 - 0200 1. Child Support Family Support $ per effective Per continuing order 2. Maintenance Section 71 $ per effective Per continuing order terminates 3. Health insurance premium $ per effective Per continuing order 4. Repay birth exp of $ @ $ per effective Per continuing order 5. Repay costs of $ @ $ per effective Per continuing order 6. Other: of $ @ $ per effective Per continuing order 7. Total arrearages owed: Child Support $ as of: ; Payable $ per effective Family Support $ as of: ; Payable $ per effective Maintenance/Sec. 71 $ as of: ; Payable $ per effective Other $ as of: ; Payable $ per effective 8. Health ins: [Check one] BOTH PARENTS Petitioner/Joint Petitioner A Respondent/Joint Petitioner B to provide if/when available at reasonable cost NO ORDER NOT AVAILABLE Employer providing insurance if different than above [Name, Address, Phone and Fax]: 9. Uninsured medical expense: (specify) Parents split evenly Other: 10. Tax exemption: CP NCP NCP if current Even years Odd years Other 11. Other: [Specify] Form prepared by: [Name] Date: Daytime Phone: Court Official: [Name] Date: DISTRIBUTION: 1. Court 2. Child Support Agency American LegalNet, Inc. www.FormsWorkFlow.com