(1) Name of Person Filing : Phone Number(s): / In this case I am Petitioner or Respondent Or represented by Attorney (IF) Attorney, Name: Bar No.: Atty. Email: Atty. Phone: SUPERIOR COURT OF ARIZONA IN MARICOPA(2) COUNTY For Clerk’s Use Only PARENT’S WORKSHEET FOR CHILD SUPPORT (3) Petitioner (4) Case No. (3) Respondent (4) ATLAS (5) Total Number of Children: (6) Parent with Primary Custody: Father Mother (7) Parent who is filing this form: Father Mother (8) Gross Income figures for the OTHER PARENT are: ACTUAL, with proof, such as a recent W2 or pay stub attached, or other party’s signed statement. ESTIMATED, based on facts or knowledge of pay before promotion or of others in similar job. ATTRIBUTED, based on what other party could and should be earning (see Guidelines 5e). FATHER Gross Income (Pre-Tax Income. Before deductions.) (9) Combined Adjusted Gross Income (15) (16) $ $ $ $ + - $ Basic Child Support Obligation $ (17) (18) (19) (20) $ Adjusted Gross Income $ $ $ $ (14) + - $ (10) (11) (12) (13) $ $ $ $ $ Spousal Maintenance Paid Spousal Maintenance Received Child Support Paid/Contributed Other Support of Children Paid MOTHER $ Plus Costs for: Medical/Dental/Vision Insurance Childcare Education Expenses Extraordinary/Special Needs Child Expenses No. of Children Age 12 or Over $ $ $ $ Adjustment % (21) Total Adjustments for Costs (22) Total Child Support Obligation (23) $ © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED $ DRS12f-121208 Page 1 of 2 PWC American LegalNet, Inc. www.FormsWorkFlow.com Case No. FATHER MOTHER % Each Parent’s % of Combined Income Each Parent’s Share of Tot. Support Obligation % (24) (25) $ $ Adjustment for Non Custodial Parent’s Costs Associated with Parenting Time Using Table A No. of Days x Line (16) $ (26) Table B = % Adjustment (from table) (Basic Child Support Obligation) $ Less Noncustodial Parent’s Costs for: Medical/Dental/Vision Insurance* $ Childcare* $ Education Expenses* $ Extraordinary/Special Needs Child Expenses* $ *Subtract here ONLY if ADDED-IN items 17-20 above (27) $ (28) (29) (30) (31) $ $ $ $ Adjustments Subtotal $ (32) $ Preliminary Child Support Amount $ (33) $ $ (34) $ (35) $ Self Support Reserve Test for Parent Who Will Pay Amount from Line (14) Minus Reserve Amount Total (Adj. Gross Inc.) - $775 Child Support to be Paid by: Father = Mother $ Share of Travel Expenses Related to Parenting Time* % (36) % % (37) % *Only for expenses related to travel over 100 miles, one way. Share of Medical/Dental/Vision Costs Not Paid by Insurance I declare under penalty of perjury that the foregoing is true and correct. Executed on: Date © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Signature of Parent DRS12f-121208 Page 2 of 2 PWC American LegalNet, Inc. www.FormsWorkFlow.com