FA-614, 11/18 Order Relating To: Paternity/Custody/Placement/Visitation/Support/Health Care Expenses Ch. 767, Wisconsin Statutes 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: STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN RE: THE MARRIAGE PATERNITY OF Petitioner/Joint Petitioner A and Respondent/Joint Petitioner B The State of Wisconsin (Child Support Agency) is is not a party to this action. Order Relating To Paternity Legal Custody Physical Placement Vi sitation Child Support Health Care Expenses Case No. THE COURT FINDS: 1. The parties are subject to A. a pending action for Divorce Annulment Legal Separation Paternity Independent action to determine legal custody of the child or visitation rights. OR B. an order that has been granted in an action affecting the family determining: (Check all that apply) Legal Custody Periods of Physical Placement Visitation Rights Child Support Coverage of Health Care Expenses 2. A hearing was conducted in this matter on [Date] . THE COURT ORDERS: 1. The order be entered modified with respect to A. Paternity. See attached Specifically: B. Legal Custody for the following children: 1) Joint legal custody with both parents. 2) Sole legal custody with [Name of Parent] 3) Other: See attached C. Physical Placement for the following children: 1) Primary physical placement with [Name of Parent] . 2) Shared placement. 3) The new placement schedule for the changes above is as follows: American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-614, 11/18 Order Relating To: Paternity/Custody/Placement/Visitation/Support/Health Care Expenses Chapter 767, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 5 See attached 4) Placement with [Name of Parent] is required to be supervised. unsupervised. 5) Other: D. Visitation Rights of Certain Persons under 247247 767.43 or 767.44, Wis. Stats. See attached Specifically: . E. Child Support. 1) Based on the below standard calculation, child support shall be paid by to per in the amount of $ . Child Support based on gross income and the child support percentage of income standards. The standard calculation that applies to this case is 17% for one child. split-placement formula. 25% for two children. shared-placement formula. 29% for three children. serial-family parent formula. 31% for four children. low-income payer formula. 34% for five or more children. high-income payer formula. 2) Child Support Order and basis for a Deviation. a. Based on the above standard calculation, the parties understand that child support would be paid by to per in the amount of $ . b. The court orders a deviation from that amount of child support. 1. A cash contribution from F.2. or F.3.b. below increases decreases this child support amount by (If no deviation, . 2. A deviation is based on: [Explain the reasons for any other deviation here] and this increases decreases this child support amount by (If no deviation, enter $ . 3. The net amount of the child support payment shall begin , 20 in the amount of $ (If no child support is to be paid, ente . 3) Issue of child support is reserved and a referral shall be made to the child support agency. F. Health Care Expenses. Parents are required to provide private health insurance for their minor child(ren) if service providers t is reasonable. Reasonable cost is defined as the difference between single and family coverage where the added cost does not exceed 10% 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-as the increase does not exceed 10% of the non-monthly income available for child support. The parties agree that such medical insurance coverage for the minor child(ren) including medical, dental, orthodontic, hospital, psychiatric, counseling, drug and other health expenses which is currently offered shall be provided and paid by 1) both parties shall provide private health insurance and neither parent is required to make a cash contribution to the other. 2) 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. 3) a comprehensive private health insurance policy is not available to either parent at a reasonable cost. Petitioner/Joint Petitioner A Respondent/Joint Petitioner B has enrolled in shall promptly apply for Public Health Insurance. a. There is no out of pocket expense for the above Public Health Insurance. American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-614, 11/18 Order Relating To: Paternity/Custody/Placement/Visitation/Support/Health Care Expenses Chapter 767, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 5 b. Out of pocket cost for 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 accessible private health insurance becomes available at a reasonable cost to either parent, that parent shall enroll the child(ren) as covered dependents under his/her health insurance. 4) Petitioner/Joint Petitioner A Respondent/Joint Petitioner B does not have free health insurance available and has income below 150% of the federal poverty level and is therefore unable to make a cash contribution toward the cash medical support obligation is $0. If accessible private health insurance becomes available at a reasonable cost to either parent, that parent shall enroll the child(ren) as covered dependents under his/her health insurance. The insuring parent shall provide the other parent and the child support agency with copies of policy information and insurance cards. The insuring parent shall inform the child support agency about any change in his/her employment and the availability of insurance. G. Other: See attached 2. All provisions of any 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 he child(ren) are already enrolled under another private health insurance plan or unless the paren150% of the federal poverty level. 4. Change of Residence of Children. If this order established or modified custody or placement in any way, you are informed of the following: Each parent must notify the other parent, the child support agency, and the clerk of court 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. The address provided to the court is the address on which the other parties may rely for service of any motion relating to modification of legal custody or physical placement or to relocating the childs residence. o 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. 5. Parties are notified of the provisions of 247 948.31, Wis. Stats. as follows: 948.31 Interference with custody by parent or others. (1) 1. A parent or other person having legal custody of the child under an order or judgment in an action for divorce, legal separation, annulment, child custody, paternity, gu