Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-4126VA, 05/19 Stipulation for Temporary Order- With Minor Children 247247767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 7 Enter the name of the county in which you are filing this case. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Enter the name of Petitioner/Joint Petitioner A. IN RE: THE MARRIAGE OF Petitioner/Joint Petitioner A Name (First, Middle and Last) and Enter the name of Respondent/ Joint Petitioner B. Stipulation for Temporary Order With Minor Children D ivorce - 40101 Legal Separation - 40201 Case No. Check divorce or legal separation. NOTE: Enter the case number, if known. If not leave blank. Respondent/Joint Petitioner B Name (First, Middle and Last) SUMMARY OF PERSONAL INFORMATION In 1, enter the requested information about Petitioner/ Joint Petitioner A. 1. Petitioner/Joint Petitioner A: Address Address City State Zip Dates of birth should be written in the following format: [Month, Day, Y ear]. Date of birth Gross monthly income $ Employer name Address of payroll office Include area codes with the requested phone numbers. City State Zip Phone Fax In 2, enter the requested information about Respondent/ Joint Petitioner B. 2. Respondent/Joint Petitioner B: Address Address City State Zip Dates of birth should be writt en in the following format: [Month, Day, Y ear]. Date of birth Gross monthly income $ Employer name Address of payroll office Include area codes with the requested phone numbers. City State Zip Phone Fax STIPULATION The parties agree that the following terms be in effect until the final hearing of this action except as modified by a future order of the court. 1. SUMMARY OF FINANCIAL AGREEMENTS For A1, check a or b. If b, enter the monthly amount of maintenance and the month and year on which the payments will begin. A. MAINTENANCE . (Spousal Support) 1) Petitioner/ Joint Petitioner A a. g ives up right to receive maintenance at this time. b. Respondent/ Joint Petitioner B shall pay maintenance to Petitioner/ Joint Petitioner A in the amount of $ per month beginning on the first day of the month of , 20 . For A2, check a or b. If b, enter the monthly amount 2) Respondent/ Joint Petitioner B a. g ives up right to receive maintenance at this time. American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-4126VA, 05/19 Stipulation for Temporary Order with Minor Children 247247767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 7 of maintenance and the month and year on which the payments will begin. b. Petitioner/ Joint Petitioner A shall pay maintenance to the Respondent/ Joint Petitioner B in the amount of $ per month beginning on the first day of the month of , 20 . B. MINOR CHILDREN . The minor children (age 17 or younger) born to or adopted together by the parties before or during our marriage are Enter the name, date of birth [month, day, year] for each child under the age of 18. Name of Minor Child Date of Birth C. MEDICAL AND HEALTH C ARE EXPENSES . In C, check a, b, c, or d. You may check both b and d if both apply; otherwise, check only one box. 1) 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 . Reasonable cost is defined as the total amount paid for insurance coverage where the cost does not exceed 10% 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 contribution does not exceed 10% of the non - such medical insurance coverage for the minor child(ren) including medical, dental, orthodontic, hospital, psychiatric, counseling, drug and o ther health expenses which is currently offered shall be provided and paid by 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 par ent 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 D. Child Sup port and Financial Expenses below. If c, indicate who will enroll the child in public health insurance and any out of pocket costs. c. A comprehensive private health insurance policy is not available to either par ent at a reasonable cost. Petitione r/ 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. NOTE: Child Support generally includes costs for food, shelter, clothing, transportation, personal care and incidental recreational costs. 2. 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 D.Child Support and Financial Expenses below. If a n accessible private health insurance policy becomes available at a reasonable cost to either parent, that parent shall enroll the child(ren) as covered dependents under his/her health insurance. d. Petitioner/ Joint Petitioner A Respondent/ Joint Petitioner B does not have free health insurance available and ha s income below 150% of the federal poverty level and is therefore unable to make a cash contribution toward the cost $0. If accessible private health insurance becomes ava ilable 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 informat ion and insurance cards. The insuring parent shall inform the child support agency about any change in employment and the availability of insurance. American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-4126VA, 05/19 Stipulation for Temporary Order with Minor Children 247247767.225 and 767.34, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 7 Enter the percentage that each parent will pay in a and b (if different than 50%). The total must equal 1 00%. 2) Uninsured Health Care Expenses . Payments for health care expenses for the minor child ( ren ) not covered by insurance, including medical, dental, orthodontic, hospital, psychiatric, counseling, drug and other health expenses shall be paid as follows: a. Petitioner/ Joint Petitioner A to pay 50% of the total amount. Other: % b. Respondent/ Joint Petitioner B to pay 50% of the total amount. Other: % Enter the number of days for the deadline if other than 60 days . 3) Reimbursements. Any request for reimbursement from the other party for medical insurance and uninsured health care expenses shall be made in writing. The other party shall pay their required percentage within 60 days after receiving a written request. Other: days. In D, check the appropriate method of calculation for child support. D. CHILD SUPPORT AND FINANCIAL EXPENS ES . 1) The child support percentage of income standards, the standard calculation, based on gross income 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. frequency (weekly, bi - weekly, monthly, semi - monthly) and standard child support amount in a. 31% for four children. low - income payer formula. 34% for five or more children . hig