GN-4510, 05/18 Order for Reimbursement for Costs of Representation (Chapter 55) 24755.107, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Order for Reimbursement for Costs of Representation (Chapter 55) Case No. THE COURT FINDS: 1. The above-named individual was the subject of an action under Chapter 55, Wisconsin Statutes and had the right to representation by an attorney and an attorney was appointed. 2. The individual is is not financially able to reimburse for some or all of the costs of representation due to having been found indigent, partially indigent or not indigent. 3. The individualcosts of representation is undetermined. 4. The individual mailing address is THE COURT ORDERS: 1. The Office of the State Public Defender to conduct an indigency determination under 247977.07, Wis. Stats., and report to the court by [Date] . 2. No reimbursement is required because the individual is indigent. 3. The guardian of the estate or individual authorized representative to reimburse the State of Wisconsin for costs of representation in the total amount of $ , not to exceed $120 if partially indigent or $480 if not indigent. The total amount due be paid by ; OR The amount due be paid at a rate of $ /month. The first payment is due on and on the day of each month thereafter until paid in full. 4. Payment made to . 5. Other: THIS IS A FINAL ORDER FOR THE PURPOSE OF APPEAL. American LegalNet, Inc. www.FormsWorkFlow.com GN-4510, 05/18 Order for Reimbursement for Costs of Representation (Chapter 55) 24755.107, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 DISTRIBUTION: 1. Court 2. 3. 4. Corporation Counsel 5. Social worker/ County Dept. of Human Services 6. Spouse/Adult Children/Parent of Minor 7. Facility, if any 8. Other: American LegalNet, Inc. www.FormsWorkFlow.com