FA-604B, 05/17 Order to Change: Custody/Physical Placement/Support/Maintenance/Arrears Payment 247247767.451, 767.461, 767.553, 767.59, and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 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 Mark marriage or paternity. If paternity, enter initials of child. IN RE: THE MARRIAGE PATERNITY OF Order on Stipulation to Change Legal Custody Physical Placement Child Support Maintena nce Family Support Arrears Payment/Balances Other: Case No. Enter the name, address, and daytime phone number of the petitioner/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 and On the far right, mark the box for the change(s) you are requesting and enter the original case number. Enter the name, address, and daytime phone number of the respondent/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 number Mark if the State of WI 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. THE COURT ADOPTS AS FINDINGS THE FACTS SET FORTH IN THE STIPULATION DATED . For Court Use Only. To be used with FA - 604A. THE COURT FURTHER FINDS: Deviation from the child support percentage standards meets the requirements of 247 767.511(1n), Wis. Stat s. THE COURT ORDERS: A. The stipulation is approved . 1. T he previous judgment or order is amended accordingly. 2. All provisions of the previous judgment or order not amended by this order remain in full effect. 3. Whenever private, accessible and reasonably - priced health insurance becomes available to either parent at a reasonable cost, that parent shall enroll the child(ren) as covered dependents under his/her health insurance, unless the child(ren) are already enr olled American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-604B, 05/17 Order to Change: Custody/Physical Placement/Support/Maintenance/Arrears Payment 247247767.451, 767.461, 767.553, 767.59, and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 under another private health insurance plan or unless the parent's income is below 150% of the federal poverty level. B. The stipulation is denied because C. The court hearing scheduled for [Date] , 20 is removed from the court's calendar. If this order modified legal custody or physical placement in any way, you are informed that: 1. Each parent must notify the other parent, the child support agency, and the clerk of courts of the address at which they may be served within 10 business days of moving to that address. The address may be a street or post office address. 2. The address provided to the court is the address on which the ot her parties may rely for service of any motion relating to modification of legal custody or physical placement or to 3. A parent granted periods of physical placement with the child must obtain a court order before relocating with the child 100 miles or more from the other parent if the other parent also has court - ordered periods of physical placement with the child. American LegalNet, Inc. www.FormsWorkFlow.com