DR625 Eff. 1/2015 BUTLER COUNTY DOMESTIC RELATIONS COURT CHILD SUPPORT COMPUTATION WORKSHEET SPLIT PARENTAL RIGHTS AND RESPONSIBILITIES NAME OF PARTIES: NUMBER OF MINOR CHILDREN: NUMBER OF MINOR CHILDREN WITH MOTHER: CASE NUMBER: FATHER: COLUMN I FATHER COLUMN II MOTHER COLUMN III COMBINED INCOME 1. a. ANNUAL GROSS INCOME FROM EMPLOYMENT OR, WHEN DETERMINED APPROPRIATE BY THE COURT OR AGENCY, AVERAGE ANNUAL GROSS INCOME FROM EMPLOYMENT OVER A REASONABLE PERIOD OF YEARS. (EXCLUDE OVERTIME, BONUSES, SELF-EMPLOYMENT INCOME , OR COMMISSIONS)................................................. b. AMOUNT OF OVERTIME, BONUSES, AND COMMISSIONS (YEAR 1 REPRESENTING THE MOST RECENT YEAR) Father Mother YR. 3 (THREE YEARS AGO) YR. 2 (TWO YEARS AGO) YR.1 (LAST CALENDAR YEAR) AVERAGE (INCLUDE IN COL. I AND/OR COL. II THE AVERAGE OF THE THREE YEARS OR THE YEAR 1 AMOUNT, WHICHEVER IS LESS, IF THERE EXISTS A REASONABLE EXPECTATION THAT THE TOTAL EARNINGS FROM OVERTIME AND/OR BONUSES DURING THE CURRENT CALENDAR YEAR WILL MEET OR EXCEED THE AMOUNT THAT IS THE LOWER OF THE AVERAGE OF THE THREE YEARS OR THE YEAR 1 AMOUNT. IF, HOWEVER, THERE EXISTS A REASONABLE EXPECTATION THAT THE TOTAL EARNINGS FROM OVERTIME/BONUSES DURING THE CURRENT CALENDAR YEAR WILL BE LESS THAN THE LOWER OF THE AVERAGE OF THE 3 YEARS OR THE YEAR 1 AMOUNT, INCLUDE ONLY THE AMOUNT REASONABLY EXPECTED TO BE EARNED THIS YEAR.).................... 2. FOR SELF-EMPLOYMENT INCOME: a. GROSS RECEIPTS FROM BUSINESS.......................................... b. ORDINARY AND NECESSARY BUSINESS EXPENSES......... c. 5.6% OF ADJUSTED GROSS INCOME OR THE ACTUAL MARGINAL DIFFERENCE BETWEEN THE ACTUAL RATE PAID BY THE SELF-EMPLOYED INDIVIDUAL AND THE F.I.C.A. RATE............................................................................ d. ADJUSTED GROSS INCOME FROM SELF-EMPLOYMENT (SUBTRACT THE SUM OF 2b AND 2c FROM 2a)................... 3. ANNUAL INCOME FROM INTEREST AND DIVIDENDS (WHETHER OR NOT TAXABLE) .............................................. DR0706121 Parental Rights and Responsibilities Child Support Computation Worksheet (Revised 03/11/2009) American LegalNet, Inc. www.FormsWorkFlow.com COLUMN I FATHER 4. ANNUAL INCOME FROM UNEMPLOYMENT COMPENSATION......................................................................... ANNUAL INCOME FROM WORKERS' COMPENSATION, DISABILITY INSURANCE BENEFITS, OR SOCIAL SECURITY DISABILITY/RETIREMENT BENEFITS ............... COLUMN II MOTHER COLUMN III COMBINED 5. 6. 7. OTHER ANNUAL INCOME (IDENTIFY).................................... a. TOTAL ANNUAL GROSS INCOME (ADD LINES 1a, 1b, 2d AND 3-6)....................................................................................... b. HEALTH INSURANCE MAXIMUM (MULTIPLY LINE 7a BY 5%) ...................................................................... ADJUSTMENTS TO INCOME 8. ADJUSTMENTS FOR MINOR CHILDREN BORN TO OR ADOPTED BY EITHER PARENT AND ANOTHER PARENT WHO ARE LIVING WITH THIS PARENT; ADJUSTMENT DOES NOT APPLY TO STEPCHILDREN (NUMBER OF CHILDREN TIMES FEDERAL INCOME TAX EXEMPTION LESS CHILD SUPPORT RECEIVED, NOT TO EXCEED THE FEDERAL TAX EXEMPTION) ................................................... 9. ANNUAL COURT-ORDERED SUPPORT PAID FOR OTHER CHILDREN...................................................................................... ANNUAL COURT-ORDERED SPOUSAL SUPPORT PAID TO ANY SPOUSE OR FORMER SPOUSE ........................................ AMOUNT OF LOCAL INCOME TAXES ACTUALLY PAID OR ESTIMATED TO BE PAID ................................................. MANDATORY WORK-RELATED DEDUCTIONS SUCH AS UNION DUES, UNIFORM FEES, ETC. (NOT INCLUDING TAXES, SOCIAL SECURITY, OR RETIREMENT) ..................... TOTAL GROSS INCOME ADJUSTMENTS (ADD LINES 8 THROUGH 12)............................................................................... 10. 11. 12. 13. 14. a. ADJUSTED ANNUAL GROSS INCOME (SUBTRACT LINE 13 FROM LINE 7)................................................................................ b. CASH MEDICAL SUPPORT MAXIMUM (IF THE AMOUNT ON LINE 7a, COL. I, IS UNDER 150% OF THE FEDERAL POVERTY LEVEL FOR AN INDIVIDUAL, ENTER $0 ON LINE 14b, COL. I. IF THE AMOUNT OF LINE 7a, COL. I, IS 150% OR HIGHER OF THE FEDERAL POVERTY LEVEL FOR AN INDIVIDUAL, MULTIPLY THE AMOUNT ON LINE 14a, COL. I, BY 5% AND ENTER THIS AMOUNT ON LINE 14b, COL. I. IF THE AMOUNT ON LINE 7a, COL. II, IS UNDER 150% OF THE FEDERAL POVERTY LEVEL FOR AN INDIVIDUAL, ENTER $0 ON LINE 14b, COL. II. IF THE AMOUNT ON LINE 7a, COL. II, IS 150% OR HIGHER OF THE FEDERAL POVERTY LEVEL FOR AN INDIVIDUAL, MULTIPLY THE AMOUNT ON LINE 14a, COL. II, BY 5% AND ENTER THIS AMOUNT ON LINE 14b, COL. II.) ......... 15. COMBINED ANNUAL INCOME THAT IS BASIS FOR CHILD SUPPORT ORDER (ADD LINE 14, COL. I AND COL II)........... American LegalNet, Inc. www.FormsWorkFlow.com COLUMN I FATHER 16. PERCENTAGE OF PARENT'S INCOME TO TOTAL INCOME a. FATHER (DIVIDE LINE 14a, COL. I BY LINE 15, COL III) ... % COLUMN II MOTHER COLUMN III COMBINED b. MOTHER (DIVIDE LINE 14a, COL. II, BY LINE 15, COL. III) 17. % BASIC COMBINED CHILD SUPPORT OBLIGATION (REFER TO SCHEDULE, FIRST COLUMN, LOCATE THE AMOUNT NEAREST TO THE AMOUNT ON LINE 15, COL. III, THEN REFER TO COLUMN TO COLUMN FOR NUMBER OF CHILDREN IN THIS FAMILY. IF THE INCOME OF THE PARENTS IS MORE THAN ONE SUM BUT LESS THAN ANOTHER YOU MAY CALCULATE THE DIFFERENCE.)................. FOR CHILDREN FOR WHOM MOTHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN.................................... FOR CHILDREN FOR WHOM FATHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN.................................... 18. ANNUAL SUPPORT OBLIGATION PER PARENT a. OF FATHER FOR WHOM MOTHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN (MULTIPLY LINE 17, COL. I, BY LINE 16a)....................................................... b. OF MOTHER FOR WHOM FATHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN (MULTIPLY LINE 17, COL. II, BY LINE 16b)...................................................... PAID BY FATHER PAID BY MOTHER 19. ANNUAL CHILD CARE EXPENSES FOR CHILDREN WHO ARE THE SUBJECT OF THIS ORDER THAT ARE WORK-, EMPLOYMENT TRAINING-, OR EDUCATION-RELATED, AS APPROVED BY THE COURT OR AGENCY (DEDUCT TAX CREDIT FROM ANNUAL COST, WHETHER OR NOT CLAIMED). 20. a. MARGINAL, OUT OF POCKET COST, NECESSARY TO PROVIDE FOR HEALTH INSURANCE FOR THE CHILDREN WHO ARE THE SUBJECT OF THIS ORDER (CONTRIBUTING COST OF PRIVATE FAMILY HEALTH INSURANCE, MINUS THE CONTRIBUTING COST OF PRIV