SC-5510VA, 11/17 Statement on Eligibility to Receive or Receipt of Emergency Assistance (Small Claims) 247799.40(4), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional materials. Enter the name of the county in which this case was filed. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Enter the Plaintiff(s) name . Plaintiff(s): - vs - Defendant(s): Enter the Defendant( s ) name . Enter the eviction case number. Amended Statement on Eligibility to Receive or Receipt of Emergency Assistance (Small Claims) Case No. I STATE: 1. I am the defendant in this case and the court previously ordered a stay of these eviction proceedings pursuant to 247799.40(4), Wis. Sta ts., based upon my application for emergency assistance pursuant to 24749.138, Wis. Stats. 2 . A copy of the notice of decision on my request for emergency assistance is attached. In 3 , enter the date. 3 . The decision stated I am ineligible for emergency assistance . eligible for emergency assistance. I received the emergency assistance on [Dat e] . Sign and print your name, and enter the date. Signature Print or Type Name Date DISTRIBUTION: 1. Court 2. Parties American LegalNet, Inc. www.FormsWorkFlow.com