ME-931, 08/08 Order for Reimbursement for Costs of Representation (Chapter 51) 24751.605, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 1 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name of Subject Date of Birth Amended Order for Reimbursement for Costs of Representation ( Chapter 51 ) Case No. THE COURT FINDS: 1. The person named above was the subject of an action under Wisconsin Statutes Chapter 51, had the right to representation by an attorney and an attorney was appointed. 2. The subject 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. s of representation is undetermined. 4. T . 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 subject is indigent. 3. The subject reimburse the State of Wisconsin for costs of representation in the total amount of $ , not to exceed $30 if partially indigent or $120 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 THIS IS A FINAL ORDER FOR THE PURPOSE OF APPEAL. DISTRIBUTION: 1. Court 2. Subject 3. State Public Defender Office American LegalNet, Inc. www.FormsWorkFlow.com