La Crosse County Certification Of Change In Work Status
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1PAYOR NAME:_____________________________
COURT CASE/IV-D No
_____________/____________
.
PAYEE NAME: ____________________________ FOR MONTH OF: __________________________
La Crosse County Certification of Change in Work Status
Adjustment Available Under Local Court Rule 904
Pursuant to your court order an order may be adjusted under Local Court Rule 904 adopted by La
Crosse County Judicial Officials. If the payer is not working for a legitimate reason or has an
involuntary reduction in hours, the support obligation shall be converted to the appropriate
percentage under the Wisconsin Child Support Guidelines. The calculation will be based upon the
gross income being received from all income sources including: Workers Compensation,
Unemployment Compensation, disability insurance payments (non-Social Security based) or
severance pay. For Unemployment Compensation calculations, periods of no employment or self
employment that occurred during the base period will not be included in calculating reductions in
child support. The calculations indicated below illustrate the change to the order.
UNEMPLOYMENT INSURANCE
# of Child(ren)
Percentage
UI Benefit/Period
Child Support Amount/Period
______
_______%
$____________/________
$_________________/_____
WORKER’S COMPENSATION
# of Child(ren)
Percentage
WC Benefit/Period
Child Support Amount/Period
______
_______%
$____________/________
$_________________/_____
OTHER COMPENSATION
________________________
Compensation Type
# of Child(ren)
Percentage
Other Benefit/Period
Child Support Amount/Period
______
_______%
$____________/________
$_________________/_____
_________________________________________
___________________________________
CHILD SUPPORT AGENCY
NON-CUSTODIAL PARENT
DATE
*** Initial requests will take effect on the day completed.
*** Subsequent requests after the initial request require a new form to be completed every
month and must be completed prior to the first day of the month in order to receive the
reduction. Requests received after the first of the month won’t take effect until the
following month.
*** If the payer loses eligibility for unemployment/worker’s compensation the prior order
resumes.
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CP --Pink
Clerk of Courts – Gold
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