District Court Denver Juvenile Court ____________________________________ County, Colorado Court Address: In Re: The Marriage of: Parental Responsibilities concerning: Petitioner: and Co-Petitioner/Respondent: COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: FAX Number: Division: E-mail: Atty. Reg. #: Courtroom: WORKSHEET A – CHILD SUPPORT OBLIGATION: SOLE PHYSICAL CARE Children Date of Birth Check box of parent with 273 or more overnights per year* 1. Monthly Gross Income Children Mother Date of Birth Combined Father $ $ a. Plus maintenance received + + b. Minus maintenance paid - - - - - - 2. Monthly Adjusted Gross Income (If either the paying $ $ c. Minus ordered child support payments for other children pursuant to §14-10-115(6)(a), C.R.S. d. Minus legal responsibility for children not of this marriage/relationship pursuant to §14-10-115(6)(b)(I), C.R.S. e. Minus ordered post-secondary education contributions** parent’s income or Combined Income is less than $850.00, enter $50.00 on line 11 for paying parent.) 3. Percentage Share of Income (Each parent’s income from line 2 divided by Combined Income) 4. a. Basic Combined Obligation (Apply line 2 Combined column to Child Support Schedule) b. Each parent’s share of basic support obligation (Each parent’s percentage from line 3 times combined obligation in 4a) 5. Low-Income Adjustment (If paying parent’s income in line 6. % $ % $ $ $ $ $ $ $ $ $ $ $ $ $ 2 is less than $1850.00, see Low-income Worksheet on page 2) Adjustments (Expenses paid directly by each parent) a. Work-related Child Care Costs - Actual costs minus Federal Tax Credit pursuant to §14-10-115(9), C.R.S. b. Education-related Child Care Costs pursuant to §14-10-115(9), C.R.S. c. Health Insurance premium costs – Children’s portion only pursuant to §14-10-115(10), C.R.S. (See page 2 for calculation worksheet) d. Extraordinary Medical Expenses - Uninsured only pursuant to §14-10-115(10), C.R.S. JDF 1820M R1/08 WORKSHEET A – CHILD SUPPORT OBLIGATION: SOLE PHYSICAL CARE Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com e. Extraordinary Expenses - Agreed to by parents or by order of the Court pursuant to §14-10-115(11)(a), C.R.S. f. Minus Extraordinary Adjustments pursuant to §14-10-115(11)(b), C.R.S. 7. Total Adjustments (For each column, add 6a, 6b, 6c, 6d and 6e. Subtract line 6f then add two totals for Combined column amount) 8. Each Parent’s Fair Share of Adjustments (Line 7 Combined column times line 3 for each parent) $ $ $ $ $ $ $ $ 9. Each Parent’s Share of Total Child Support $ Obligation (Add lines 4b (or line 5 if less) and line 8 for each $ $ parent) $ $ 11. Recommended Child Support Order (Subtract line 10 $ $ 10. Paying Parent’s Adjustment (Enter line 7 for parent with less parenting time only) from line 9 for the paying parent only. column blank) Leave receiving parent Comments: *The children reside with one parent for 273 or more overnights per year. If this is not the case, use Worksheet B. **This adjustment applies only to modification of child support orders entered between 7/1/91 and 7/1/97 that provide for post-secondary education expenses pursuant to § 14-10-115(15)(c), C.R.S. Prepared by: Date: Signature: ________________________________Print Name: ___________________________ Low-Income Adjustment Worksheet If the parents’ combined monthly adjusted gross income is more than $850.00 and the monthly adjusted gross income of the parent with fewer overnights per year is less than $1850.00, use this calculation worksheet to determine the adjustment allowed for that parent. Low-income Adjustment Calculation Adjusted monthly gross income of parent with fewer overnights (paying parent) from line 2 $ minus $900.00 = $ times 40% (.40) = $ Plus one of the following, according to number of children 1 child = $75.00 2 children = $150.00 3 children = $225.00 4 children = $275.00 5 children = $325.00 6 or more children = $350.00 + Low-income adjustment amount (#5 on worksheet) $ $ If this amount is less than the amount on line 4b (on page 1) for the parent with fewer overnights per year, this parent qualifies for the Low-income Adjustment. Enter this amount on line 5 in that parent’s column on page 1. If this number is a negative or zero, enter zero. Heath Insurance Premium Calculation If the actual amount of the health insurance premium that is attributable to the child(ren) who are the subject of this order is not available or cannot be verified, the total cost of the premium should be divided by the number of persons covered by the policy to determine a per person cost. This amount is then multiplied by the number of children who are the subject of this order and are covered by the policy. This amount is then entered on line 6c on page 1 of this form. $ ÷ Total Premium Number of Persons Covered by the Policy =$ x Per Person Cost = Number of Children Who Are the Subject of this Order JDF 1820M R1/08 WORKSHEET A – CHILD SUPPORT OBLIGATION: SOLE PHYSICAL CARE Children’s Portion of Cost of Health Insurance Premium (Enter on line 6c) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com