Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-604A, 05/19 Stipulation to Change: Custody/Physical Placement/Support/Maintenance/Arrears 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 4 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 Enter the name, address, and daytime ph one 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. Stipulation to Change Legal Custody Physical Placement Child Su pport Maintenance Family Support Arrears Payment / Balances Other: Case No. Enter the name, address, and daytime ph one 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 Wisconsin is a party or n ot. If you are unsure, call your local Child Support Agency. The State of Wisconsin (Child Support Agency) is is not a party to this action. FINDINGS/BASIS In 1.A and B, complete the gross income (before taxes) for both parties. The parties agree that the requested changes are based on the following facts: 1. Current Income and Other Information In C, enter number of children under 18, and under 19 and pursuing a course of education leading to a high school diploma or its equivalent. A. Petitioner/Joint Petitioner A Gross monthly income $ Employer B. Respondent/Joint Petitioner B Gross monthly income $ Employer C . Parties have children subject to the child support standard. 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. D. Health insurance for the children. 1) A comprehensive private health insurance policy is not available to either parent of the federal poverty level . 2) provides health insurance at the cost of $ per . In 2, check all that apply in A - I. If I. enter the change in circumstance that has prompted you to make this agreement. 2. 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: A. A child who was living with is now living with . B. A child is no longer eligible for child support because the child has reached age 18, or is over 18 but under 19, and is no longer pursuing a course of education leading to a high school dipl oma or its equivalent. C. O ne of the parties has or will be moving to a different residence. D. T here was not a placement schedule and the parties could not agree. E. T he availability or cost of health insurance has changed. F. E mployment or work shift of both parties has changed. G. I ncome or wages of both parties has changed. H. T he party to whom maintenance is owed has remarried. I. Other: See attached American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-604A, 05/19 Stipulation to Change: Custody/Physical Placement/Support/Maintenance/Arrears 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 4 If you are modifying financial orders, check 1. Complete all sections you are changing in 1A - 1H. 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. 1. MODIFY CURRENT FINAN CIAL ORDER(S) A. Child Support 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. 1) i s currently held open ($0) $ % per . The amount is paid by to . This child support order a. did not deviate from the percentage standard for any reason. b. did deviate from the percentage standard when it was set because: 1. The cost of health insurance paid by . 2. Other reasons as follows: 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. 2) s hall be changed to a new amount that is based on the gross income above and the following percentage of income standard: 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. In a, 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 b, enter the amount of the o rder, the frequency of the payment, and indicate which parent will be making the payments. 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 by checking a or b. * 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 . 3) Based on this standard, the support order in this case would be $ per and paid by to . See attached 4) We agree to a. set support based on this standard beginning [Date] , 20 . b. deviate from the amount of support calculated above because: 1. a cash medical contribution toward the cost of medical and health expenses increases decreases this child support amount by $ per . 2. Other : [ E xplain the reason you agree support should be dif ferent than the standard amount] This other deviation increases decreases the standard amount by $ . After calculating the deviation(s), we agree to set child support to $ per and paid by to beginning [Date ] , 20 . B. Maintenance 1) i s currently $0 $ % per and paid by [Name] . 2) s hall be changed to the following beginning [Date] , 20 . a. $ 0 . If you are changing any category in B - E , check the amount type of support you are changing. b. $ % per and paid by [Name] . C. Family Support 1) i s currently $0 $ % per and paid by [Name] . 2) s hall be changed to the following beginning [Date] , 20 . a. $ 0 . Arrears owed to the b. $ per and paid by [Name] . American LegalNet, Inc. www.FormsWorkFlow.com Petitioner/Joint Petitioner A: Respondent/Joint Petitioner B: FA-604A, 05/19 Stipulation to Change: Custody/Physical Placement/Support/Maintenance/Arrears 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 3 of 4 State cannot be modified without written approval of the Child Support Agency. Examples of types of arrears include Child Support, Child Support Interest, Maintenance, Family Support, Medical Support, and Health Care Expenses. D. Arrears Payment 1) is currently $ % per and paid by [Name] . 2) s hall be changed to the following beginning [Date] , 20 . $ % per and paid by [Name] . E . Other Arrears Balance 1) F or [ type(s) of arrears] that is currently a. $0 . b. $ owed by [Name] to . 2) Shall be changed to the following beginning , 20 a. $ 0 . The law requires that a ll child support, maintenance, and family support payments be made to the WI SCTF and NOT directly between the parties. b. $ . 2. PAYMENTS SHALL BE MA DE A. no payments are ordered . B. to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee, Wisconsi