Wisconsin Proposed Parenting Plan Page 4
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5Proposed Parenting Plan
Page 4 of 5
Case No.
_____________
H. Residence
Check a or b.
1. Current
If a, enter the address.
a.
I currently reside at:
Address
If b, enter your general
City
State
Zip
location.
b.
This is an inter-spousal battery/domestic violence case; I decline to give a specific
address, but my general location is currently
.
2. Future
a.
For the next two years it is my intention to reside at:
Check a or b.
Address
If a, enter the address at
which you intend to live
City
State
Zip
for the next two years.
b.
This is an inter-spousal battery/domestic violence case; I decline to give a specific
future address, but it is my intention to generally reside for the next two years at:
If b, enter the general
location of where you
.
intend to live for the next
two years.
I. Current Employer
1.
I am currently employed at:
Check 1 or 2.
Employer
City
If 1, enter your current
State
Days/Hrs.
employer and your
2.
This is an inter-spousal battery/domestic violence case; I decline to give my specific
general work schedule.
employment, but where I generally work is
.
If 2, enter your general
employment.
J. Health Care
1. Providers: Healthcare services will be provided to the children by the following:
Doctors/Pediatrician/Clinic
Enter the name of each
Eye/Optometrist
provider. If other, enter
Dentist/Orthodontist
the description along
Insurance/Health Plan
(if any)
with the provider name.
Other:
2. Expenses
a. Healthcare Insurance for the minor children shall be:
Check 1, 2, 3, 4 or 5.
1.
paid by me.
If 4, describe your
2.
paid by the other parent.
payment suggestion.
3.
shared equally by both of us.
4.
paid as follows:
If 5, attach the plan.
5.
See attached plan.
b. Uninsured healthcare expenses shall be:
Check 1, 2, 3, 4 or 5.
1.
paid by me.
2.
paid by the other parent.
If 4, describe your
3.
shared equally by both of us.
payment suggestion.
4.
paid as follows:
If 5, attach the plan.
5.
See attached plan.
K. Religious Upbringing
Check 1 or 2.
1.
The minor children will be raised in the following religion:
If 1, enter the name of
2.
No religious affiliation is planned.
the religion.
L. Maintaining Contact with Other Parent
I shall assist the children in maintaining contact with the other parent by:
Check all that apply in 1-
1.
direct contact through periods of placement.
10. If other, enter a
2.
telephone contact.
description.
3.
cards/letters.
4.
e-mail.
providing copies of children’s school projects.
5.
6.
providing photographs of children participating in activities.
FA-4147V, 01/09 Proposed Parenting Plan
§767.41(1m), Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
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