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SC-5510VA

Statement on Eligibility to Receive or Receipt of Emergency Assistance (Small Claims)

Wisconsin · Wisconsin Court System · Effective November 21, 2019

This form is used to tell the court whether the defendant was found eligible or ineligible for, or if they received, emergency assistance related to a small claims case. It is a voluntary form to provide this information to the court.

The court describes it as: To inform the court that defendant has been found eligible or ineligible or has received Emergency Assistance for his/her family. Voluntary form.

Open the official PDFfrom Wisconsin Court System

Where this fits in a case

General & info

Information / general use — not tied to one step of a case

This form is used by the defendant in a small claims case when the court has previously ordered a stay of eviction proceedings based on an application for emergency assistance.

Usually filed by the person responding.

Official instructions

How-to guides published by the court for this form.

Common questions

Who fills out this form?
The form is for the defendant in the case. You must sign and print your name and enter the date. Great! The form is voluntary.
What does this form relate to?
It relates to a court order that stayed eviction proceedings because the defendant applied for emergency assistance. It also mentions Wisconsin Statutes sections like §799.40(4) and §49.138.

Revision history

No changes recorded since we started tracking this form on October 10, 2026. The current version took effect November 21, 2019.

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