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 B – CHILD SUPPORT OBLIGATION: SHARED PHYSICAL CARE Children Date of Birth Children Mother Date of Birth Father 1. Monthly Gross Income $ a. Plus maintenance received + + b. Minus maintenance paid - - - - - - $ Combined $ $ 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* 2. Monthly Adjusted Gross Income 3. Percentage Share of Income (Each parent’s income % from line 2 divided by Combined Income) $ % $ 4. Basic Combined Obligation (Apply line 2 Combined column to Child Support Schedule) $ 5. Shared Physical Care Support Obligation (Line 4 times 1.5) 6. Each Parent’s Portion of Shared Physical Care $ Support Obligation (Line 3 times line 5 for each parent) 7. Overnights with Each Parent (Must total 365) $ = 365 STOP HERE IF LINE 7 IS LESS THAN 93 FOR EITHER PARENT. IF SO, USE WORKSHEET A % 8. Percentage Time with Each Parent (Line 7 ÷ 365) 9. Support Obligation for Time with Other Parent $ 10. (Line 6 times other parent’s line 8) Adjustments (Expenses paid directly by each parent) $ % $ $ JDF 1821M R1/08 WORKSHEET B – CHILD SUPPORT OBLIGATION: SHARED PHYSICAL CARE Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 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 §14-10115(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. 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] 11. Total Adjustments (For each column, add 10a, 10b, 10c, 10d and 10e. Subtract line 10f. Add two totals for Combined column amount) 12. Each Parent’s Share of Adjustments (Line 11 Combined column times line 3 for each parent) 13. Adjustments Paid in Excess of Fair Share (Line 11 minus line 12. If negative number, enter zero) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 14. Each Parent’s Adjusted Support Obligation $ $ 15. Recommended Child Support Order** (Subtract $ $ $ (Line 9 minus line 13) lesser amount from greater amount in line 14 and enter result under greater amount) Comments: *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. **If either the paying parent’s monthly adjusted gross income or the combined monthly adjusted gross income is less than $850.00, see §14-10-115(7)(a)(II)(B) and (C), C.R.S. Prepared by: Date: Signature: ________________________________Print Name: ___________________________ The amount of child support ordered for shared physical care should not be more than an order for sole physical care. Complete a Worksheet A for comparison. 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 10c 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 1821M R1/08 WORKSHEET B – CHILD SUPPORT OBLIGATION: SHARED PHYSICAL CARE Children’s Portion of Cost of Health Insurance Premium (Enter on line 10c) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com