FORM SUMMARY Name of Form: Stipulation and Order to Change: Custody/Placement/Support/ Maintenance Form Number: FA-604 ________________________________________________________________ Statutory Reference: §§767.451, 767.461, 767.553, 767.59 and 767.89, Wisconsin Statutes Benchbook Reference: FA 14 Purpose of Form: This form allows parties to stipulate to certain modifications of an original family court judgment for child placement, custody and support issues. This eliminates need for a court hearing. Who Completes It: Parties who seek the change complete the form and present it to the Child Support Agency and the court. Distribution of Form: Original to court, copies to each of the parties. The child support agency should also receive a copy of the order prior to filing for approval, if required. Accompanying Forms: Generally none. New Form/Modification: Modification; last update 01/09. Modifications: New rule which took effect Jan. 1, 2010 to DCF 150, the Percentage of Income Standard which creates requirements for establishing medical support orders. Under the new rules, a parent who has insurance coverage available that means certain defined criteria must carry that coverage and the other parent may be ordered to contribute to the cost of that coverage. That contribution would be in the form of an upward or downward deviation in the child support amount dependent on which parent is the court ordered payee. Comments: This form is for use in divorce and paternity cases. The form allows the modification of child support, family support and maintenance orders as well as issues related to placement and other non-property matters. The only way for the parties to avoid a wage assignment is for the court to make a finding of irreparable harm to the payer or because the parties have an account transfer under §767.267. If the parties are now or have in the past been the recipients of some form of public assistance (i.e. W2, food stamps, medical assistance, child care subsidy, etc.), the local child support agency must be notified before the court signs any order affecting a child support obligation to ensure that the interests of the public are protected. Child support must "sign off" on the agreement under those circumstances in the signature block provided for that agency prior to the court signing the order. The procedures for accomplishing this would be county specific. 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. Approval Date: 02/11/2010 Release Date: 09/20/2010 Posted Date: 09/22/2010 -1– American LegalNet, Inc. www.FormsWorkFlow.com Enter the name of the county in which the original case was filed. Mark marriage or paternity. If paternity, enter initials of child. Enter the name, address, and daytime phone number of the petitioner or joint petitioner from the original case file. 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 or joint petitioner from the original case file. Mark if the State of Wisconsin is a party or not. If you are unsure, you may call your local Child Support Agency. In 1A and B, complete the gross income (before taxes) for both parties. In C, enter the number of children subject to child support. In D, check 1 or 2 to indicate if private health insurance is available. If 2, indicate who provides the insurance and how much it costs. In 2, check all that apply in A-I. If I. enter the change in circumstance that has prompted you to make this agreement. For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY In RE: The marriage paternity of Petitioner/Joint Petitioner: First name Middle name Last name Current Mailing Address City State Zip Daytime phone number vs. Legal Custody Physical Placement Child Support Maintenance Family Support Arrears Balances Other: Respondent/Joint Petitioner: First name Middle name Last name Current Mailing Address City State Zip Stipulation and Order to Change: Daytime phone number The State of Wisconsin (Child Support Agency) is is not a party to this action. Case No. Findings/Basis: The parties agree that the requested changes are based on the following facts: 1. Current Income and Other Information Employer A. Wife/Mother Gross monthly income$ Employer B. Husband/Father Gross monthly income$ children subject to the child support standard. C. Parties have D. Health insurance for the children. A comprehensive private health insurance policy is not available to either parent at a 1. reasonable cost and/or neither parent’s income is currently more than 150% of the federal poverty level. provides health insurance at the cost 2. . per of $ 2. Basis for Change This agreement is based on the following substantial change in circumstance(s) that have occurred since the entry of the prior court order in this case: . is now living with a child who was living with A. a child is no longer eligible for child support because the child has reached age 18, or is B. over 18 but under 19, and is no longer pursuing a course of education leading to a high school diploma or its equivalent. one of the parties has or will be moving to a different residence. C. there was not a placement schedule and the parties could not agree. D. E. the availability or cost of health insurance has changed. both parties has changed. employment or work shift of F. both parties has changed. G. income or wages of the party to whom maintenance is owed has remarried. H. Other: I. See attached FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance Page 2 of 5 Case No. ______________ Agreements: The parties agree that the judgment or order in this case should be changed as follows, and that the court may enter this stipulation as an order without a court hearing. If you are modifying 1. financial orders, check 1. Complete all sections you are changing in 1A1H. If you are changing child support, check 1.A. In 1, enter the current child support order and check a or b. If b, check 1 or 2 and complete as required. In 2, check the standard calculation that applies to the specifics of this case after considering the gross income of the parties, other payment obligations of the parties, and physical placement of the children. Modify Current Financial Order(s) Child Support A. . The % per $ held open ($0) 1. Is currently . This to amount is paid by child support order did not deviate from the percentage standard for any reason. a. did deviate from the percentage standard when it was set because: b. . The cost of health insurance paid by 1. Other reasons as follows: 2. 2. Shall be changed to a new amount that is based on the gross income above and the following percentage of income standard: *split-placement formula. 17% for one child. *shared-placement formula. 25% for two children. **serial-family parent formula. 29% for three children. low-income payer formula. 31% for four children. high-income payer formula. 34% for five or more children *Shared-placement or Split-placement: Describe or attach the placement percentage of time with each parent See attached **Serial-family parent: Describe or attach the calculation Enter support amount based on standard calculation, frequency of payment and which party is paying. Check a or b. If b, check 1 or 2. If 2, explain and indicate the new child support amount based on the deviation. If you are changing any category in B-G, check the type of support you are changing. In 1, enter the current order by indicating the current support amount, the frequency of payment, and the name of party who currently pays or owes the money. In 2, indicate the month, day and year the new payment should begin and what you have agreed to change the support amount to by checking a or b. If b, enter the amount of the order, the frequency of the payment, and indicate which parent will be making the payments. See attached per Based on this standard, the support order in this case would be $ . to and paid by We agree to . , 20 set support based on this standard beginning a. deviate from the amount of support calculated above because: b. A cash medical contribution toward the cost of medical and health expenses 1. . per increases decreases this child support amount by $ Other (explain the reason you agree support should be different than the standard amount) 2. decreases the standard amount by increases This other deviation . $ After calculating the deviation(s), we agree to set child support to $ beginning to and paid by per . , 20 B. C. Maintenance % per 1. That is currently $ $0 . by (Name) 2. Shall be changed to the following beginning $0. a. and paid by (Name) % per b. $ Family Support $ $0 1. That is currently and paid by (Name) 2. Shall be changed to the following beginning $0. a. and paid by (Name) per $ b. FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance and paid , 20 . % per . , 20 . §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance D. Arrears Payment 1. That is currently $0 Page 3 of 5 Case No. . 2. Shall be changed to the following beginning $0. a. and paid by (Name) % per $ b. Arrears Interest Payment 1. That is currently $0 H. If I, describe the other financial agreements in as much detail as possible. Include amounts, dates, names, etc. In 2, check A or B. If B, check 1 or 2. If 2, complete the payer’s employer information. I. . and paid by . 2. Shall be changed to the following beginning $0. a. and paid by (Name) per $ b. G. , 20 % per $ (Name) F. and paid by % per $ (Name) E. ______________ , 20 . Child Support Arrears Balance and owed by (Name) $ $0 1. That is currently 2. Shall be changed to the following beginning $ 0. a. $ b. , 20 Child Support Interest Arrears Balance $ $0 1. That is currently 2. Shall be changed to the following beginning $ 0. a. $ b. , 20 . . and owed by (Name) Other Arrears Balance 1. For (type(s) of arrears) $0. a. b. owed by (Name) $ 2. Shall be changed to the following beginning $0. a. $ b. that is currently , 20 Other Financial changes as follows: 2. Payments shall be made no payments are ordered. A. to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee, B. Wisconsin 53274-0200 directly from the payer to WI SCTF (only allowable if self-employed). 1. by income assignment from the payer’s employer as indicated below: 2. Employer name Address of payroll office Zip State City Fax Phone FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance Page 4 of 5 ______________ Case No. 3. Modify In 3, if you are requesting Physical Placement Order(s) (time with children) for the following children: A. changes to physical placement check A and enter the names of the children for whom you have agreed to changes. Check 1, 2, 3, or 4, enter the parents’ names as requested and enter or attach the new placement schedule. from primary physical placement with (Name of Parent) to primary placement with (Name of Parent) from shared placement to primary placement with (Name of Parent) 2. from primary placement to shared placement. 3. from the current shared placement schedule (if any) to a new shared placement schedule. 4. The new placement schedule for the changes in 1-4 above is as follows: 1. If making a change to terms of placement related to supervision, check 5 and complete all relevant information. If other, check 6 and enter the specific information. See attached 5. 6. See attached B. If you are requesting changes to legal custody check B and enter the names of the children for whom you have agreed to changes. Check 1, 2, or 3 and enter the requested information. to require placement with (Name of Parent) unsupervised. supervised. be Other: Legal Custody (decision making) for the following children: 1. 2. 3. to joint legal custody with both parents. to sole legal custody with (Name of Parent) Other: . See attached 4. Additional changes as follows: If you are modifying anything else, check and complete 4. See attached THE COURT ADOPTS AS FINDINGS THE FACTS SET FORTH ABOVE. THE COURT FURTHER FINDS: Deviation from the child support percentage standards meets the requirements of §767.511(1n), Wisconsin Statutes. For Court Use Only. 1. Amount support would be using percentage standard is as set forth in Agreements 1.A.2. 2. Amount support deviates from percentage standard is as set forth in Agreements1.A.2.b. 3. The percentage standard is unfair for the reasons set forth in 1.A.2. Other: 4. The basis for the modification is as set forth above. Other: FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance Page 5 of 5 ______________ Case No. THE COURT ORDERS: 1. This stipulation is approved and the 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 enrolled under another private health insurance plan or unless the parent's income is below 150% of the federal poverty level. The former wife/mother must sign and print her name. Enter the date on which she signed her name. Wife/Mother Print or Type Name NOTE: This signature does not need to be notarized. Date The former husband/father must sign and print his name. Enter the date on which he signed his name. Husband/Father Print or Type Name NOTE: This signature does not need to be notarized. If either party is receiving public assistance or there is a case worker from the Child Support Agency assigned to your case, you must take this agreement to the Child Support Agency in your county for their approval. If not, mark not required. If a Guardian ad Litem has been appointed to your case, you must take this agreement to the GAL for his/her approval. Date State of Wisconsin, Child Support Agency Approved Not Approved Not Required Authorized Signature Print or Type Name Date Guardian ad Litem Approved Not Approved Not Required (No GAL has been appointed) If not, mark not required. Authorized Signature Print or Type Name Date BY THE COURT: For Court Use Only. Circuit Court Commissioner Circuit Court Judge Print or Type Name Date FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com