Form Fa-4150v - Marital Settlement Agreement - Wisconsin Circuit Court Page 6
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11Marital Settlement Agreement With Minor Children
Page 6 of 10
Case No.
_____________
In a sole legal custody arrangement, the parent not granted sole legal custody, shall file a
medical history form with the court in compliance with §767.41(7m), Wis. Stats.
Note: Physical
K. PHYSICAL PLACEMENT OF MINOR CHILDREN
Placement means
The physical placement of the minor children shall be:
where the child lives or
Shared
Primary Primary
spends their time.
Name of Minor Child
w/Mother w/Father
Shared placement
occurs when a child
spends at least 25% or
92 days per year with
each parent.
Otherwise, one parent
is considered to have
primary placement.
Enter the names of the
and the placement schedule shall be:
children. Check
a.
as listed in the attached parenting plan and/or schedule.
shared, primary
b.
as follows:
mother, or primary
father for each child.
Check a or b. If a,
See attached
attach parenting plan
L. CHILD SUPPORT
and/or a schedule. If b,
1. The child support is based on
: (All calculations are based on gross income)
describe how
17% for one child.
placement will be
25% for two children.
shared.
29% for three children.
Note: Child Support
31% for four children.
generally includes costs
34% for five or more children.
for food, shelter,
split-placement formula.
clothing,
shared-placement formula.
transportation,
serial-family payer formula.
personal care and
incidental recreational
low-income payer formula.
costs.
high-income payer formula.
If not based on options above, explain:
For 1, check the
appropriate method of
2. The parties agree that child support shall be paid as follows:
calculation.
a.
The husband shall pay child support to the wife in the amount of $
per month,
beginning on the first day of the month of
, 20
b.
The wife shall pay child support to the husband in the amount of $
per month,
beginning on the first day of the month of
, 20
c.
No child support shall be ordered from either party at this time because
.
Note: For more
3. Payments shall be made:
information on DCF 150,
a.
No payments are ordered to be made.
contact your local Child
b.
to the Wisconsin Support Collections Trust Fund (WI SCTF) at Box 74200, Milwaukee,
Support Agency.
Wisconsin 53274-0200:
1.
directly from the payer to WI SCTF
(only allowable if self-employed).
In 3, enter a or b.
2.
by income assignment from the payer’s employer as indicated below:
Employer name
If b, check 1 or 2. If 2,
Address of payroll office
enter the employer
City
State
Zip
information.
Phone
Fax
FA-4150V, 01/09 Marital Settlement Agreement With Minor Children
§767.34, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 6 of 10
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