Fillable Printable Stipulation and Order to Change Custody - Wisconsin
Fillable Printable Stipulation and Order to Change Custody - Wisconsin
Stipulation and Order to Change Custody - Wisconsin
FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 1 of 5
Enter the name of the
county in which the
original case was filed.
STATE OF WISCONSIN, CIRCUIT COURT,
COUNTY
For Official Use
Mark marriage or
paternity. If paternity,
enter initials of child.
In RE: The marriage paternity of
Enter the name, address,
and daytime phone
number of the petitioner
or joint petitioner from
the original case file.
Petitioner/Joint Petitioner:
First name Middle name Last name
Current Mailing Address
City State Zip Daytime phone number
vs.
On the far right, mark
the box for the change(s)
you are requesting and
enter the original case
number.
Stipulation and
Order to Change:
Legal Custody
Physical Placement
Child Support
Maintenance
Family Support
Arrears Balances
Other:
Case No.
Enter the name, address,
and daytime phone
number of the
respondent or joint
petitioner from the
original case file.
Respondent/Joint Petitioner:
First name Middle name Last name
Current Mailing Address
City State Zip Daytime phone number
Mark if the State of
Wisconsin is a party or
not. If you are unsure,
you may call your local
Child Support Agency.
The State of Wisconsin (Child Support Agency)
is
is not a party to this action.
Findings/Basis: The parties agree that the requested changes are based on the following facts:
1. Current Income and Other Information
A. Wife/Mother Gross monthly income $ Employer
B. Husband/Father Gross monthly income $ Employer
C. Parties have children subject to the child support standard.
D. Health insurance for the children.
1. A comprehensive private health insurance policy is not available to either parent at a
reasonable cost and/or neither parent’s income is currently more than 150% of the
federal poverty level.
2. provides health insurance at the cost of $ per
.
2. Basis for Change
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 diploma or its equivalent.
C. one of the parties has or will be moving to a different residence.
D. there was not a placement schedule and the parties could not agree.
E. the availability or cost of health insurance has changed.
F. employment or work shift of both parties has changed.
G. income or wages of both parties has changed.
H. the party to whom maintenance is owed has remarried.
I. Other:
See attached
In 2, check all that apply
in A-I. If I. enter the
change in circumstance
that has prompted you to
make this agreement.
In 1A and B, complete
the gross income
(before taxes) for both
parties.
In C, enter the number
of children subject to
child support.
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.
Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance Page 2 of 5 Case No. ______________
FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 2 of 5
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 Financial Order(s)
A. Child Support
1. Is 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:
2. Shall 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.
*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.
See attached
Based on this standard, the support order in this case would be $ per
and paid by to .
We agree to
a. set support based on this standard beginning , 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 (explain the reason you agree support should be different 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 , 20 .
B. Maintenance
1. That is currently $0 $ % per and paid
by (Name) .
2. Shall be changed to the following beginning , 20
a. $0.
b. $ % per and paid by (Name) .
C. Family Support
1. That is currently $0 $ % per
and paid by (Name) .
2. Shall be changed to the following beginning , 20
a. $0.
b. $ per and paid by (Name) .
If you are modifying
financial orders, check
1. Complete all sections
you are changing in 1A-
1H.
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.
If you are changing any
category in B-G, check
the type of support you
are changing.
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, 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.
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.
In 2, indicate the month,
day and year the new
payment should begin
and what you have
agreed to change the
support amount to by
checking a or b. If b,
enter the amount of the
order, the frequency of
the payment, and
indicate which parent
will be making the
payments.
Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance Page 3 of 5 Case No. ______________
FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 3 of 5
D. Arrears Payment
1. That is currently $0 $ % per and paid by
(Name) .
2. Shall be changed to the following beginning , 20
a. $0.
b. $ % per and paid by (Name) .
E. Arrears Interest Payment
1. That is currently $0 $ % per and paid by
(Name) .
2. Shall be changed to the following beginning , 20
a. $0.
b. $ per and paid by (Name) .
F. Child Support Arrears Balance
1. That is currently $0 $ and owed by (Name) .
2. Shall be changed to the following beginning , 20
a. $ 0.
b. $
G. Child Support Interest Arrears Balance
1. That is currently $0 $ and owed by (Name) .
2. Shall be changed to the following beginning , 20
a. $ 0.
b. $
H. Other Arrears Balance
1. For (type(s) of arrears) that is currently
a. $0.
b. $ owed by (Name)
2. Shall be changed to the following beginning , 20
a. $0.
b. $
I. Other Financial changes as follows:
2. Payments shall be made
A. no payments are ordered.
B. to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee,
Wisconsin 53274-0200
1. directly from the payer to WI SCTF (only allowable if self-employed).
2. by income assignment from the payer’s employer as indicated below:
Employer name
Address of payroll office
City State Zip
Phone Fax
3. Modify
A. Physical Placement Order(s) (time with children) for the following children:
1. from primary physical placement with (Name of Parent)
to primary placement with (Name of Parent)
2. from shared placement to primary placement with (Name of Parent)
3. from primary placement to shared placement.
In 2, check A or B.
If B, check 1 or 2.
If 2, complete the
payer’s employer
information.
If I, describe the other
financial agreements in
as much detail as
possible. Include
amounts, dates, names,
etc.
In 3, if you are
requesting changes to
physical placement
check A and enter the
names of the children
for whom you have
agreed to changes.
Check 1, 2, 3, or 4,
enter the parents’
names as requested and
enter or attach the new
placement schedule.
Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance Page 4 of 5 Case No. ______________
FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 4 of 5
4. from the current shared placement schedule (if any) to a new shared placement schedule.
The new placement schedule for the changes in 1-4 above is as follows:
See attached
5. to require placement with (Name of Parent)
be supervised. unsupervised.
6. Other:
See attached
B. Legal Custody (decision making) for the following children:
1. to joint legal custody with both parents.
2. to sole legal custody with (Name of Parent) .
3. Other:
See attached
4. Additional changes as follows:
See attached
THE COURT ADOPTS AS FINDINGS THE FACTS SET FORTH ABOVE.
THE COURT FURTHER FINDS:
Deviation from the child support percentage standards meets the requirements of §767.511(1n),
Wisconsin Statutes.
1. Amount support would be using percentage standard is as set forth in Agreements 1.A.2.
2. Amount support deviates from percentage standard is as set forth in Agreements1.A.2.b.
3. The percentage standard is unfair
for the reasons set forth in 1.A.2.
Other:
4. The basis for the modification is
as set forth above.
Other:
THE COURT ORDERS:
1. This stipulation is approved and the previous judgment or order is amended accordingly.
2. All provisions of the previous judgment or order not amended by this order remain in full
effect.
3. Whenever private, accessible and reasonably-priced health insurance becomes available to
either parent at a reasonable cost, that parent shall enroll the child(ren) as covered
dependents under his/her health insurance, unless the child(ren) are already enrolled under
another private health insurance plan or unless the parent's income is below 150% of the
federal poverty level.
If you are modifying
anything else, check
and complete 4.
If making a change to
terms of placement
related to supervision,
check 5 and complete
all relevant
information. If other,
check 6 and enter the
specific information.
For Court Use Only.
If you are requesting
changes to legal
custody check B and
enter the names of the
children for whom
you have agreed to
changes. Check 1, 2,
or 3 and enter the
requested information.
Stipulation and Order to Change: Support/Maintenance/Custody/Placement/Maintenance Page 5 of 5 Case No. ______________
FA-604, 02/10 Stipulation and Order to Change: Custody/Physical Placement/Support/Maintenance §§767.451, 767.461, 767.59, and 767.89, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 5 of 5
The former husband/father
must sign and print his
name.
Enter the date on which he
signed his name.
NOTE: This signature
does not need to be
notarized.
Husband/Father
Print or Type Name
Date
If either party is receiving
public assistance or there
is a case worker from the
Child Support Agency
assigned to your case, you
must take this agreement
to the Child Support
Agency in your county for
their approval.
If not, mark not required.
State of Wisconsin, Child Support Agency
Approved
Not Approved
Not Required
Authorized Signature
Print or Type Name
Date
If a Guardian ad Litem has
been appointed to your
case, you must take this
agreement to the GAL for
his/her approval.
If not, mark not required.
Guardian ad Litem
Approved
Not Approved
Not Required (No GAL has been appointed)
Authorized Signature
Print or Type Name
Date
BY THE COURT:
For Court Use Only.
Circuit Court Judge Circuit Court Commissioner
Print or Type Name
Date
The former wife/mother
must sign and print her
name.
Enter the date on which
she signed her name.
NOTE: This signature
does not need to be
notarized.
Wife/Mother
Print or Type Name
Date
