PRINT in BLACK ink
FA-4104V, 04/08 Summons-With Minor Children
§§767.215(2m) and 801.095, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 1 of 3
Enter the name of the
county in which you are
filing this case.
STATE OF WISCONSIN, CIRCUIT COURT,
COUNTY
Enter your name (you are
the petitioner).
Enter your address.
For Official Use
On the far right, check
divorce or legal
separation.
In RE: The marriage of:
Petitioner:
First name Middle name Last name
Address
Address
City State Zip
and
Enter your spouse’s name
(your spouse is the
respondent).
Enter your spouse’s
address.
Note: Leave case number
blank; the clerk will add
this.
Respondent:
First name Middle name Last name
Address
Address
City State Zip
Summons
With Minor Children
Divorce-40101
Legal Separation-40201
Case No.
The State of Wisconsin, to the person named above as respondent:
You are notified that your spouse has filed a lawsuit or other legal action against you. The
Petition, which is attached, states the nature and basis of the legal action.
Within 20 days of receiving this Summons, you must provide a written response, as that
term is used in ch. 802, Wis. Stats., to the Petition. The court may reject or disregard a
response that does not follow the requirements of the statutes.
The response must be sent or delivered to the following government offices:
Clerk of Court
Name of county
Address
Address
City
State Zip
County Child Support Agency
Name of agency
Address
Address
City