PARENT'S WORKSHEET FOR CHILD SUPPORT AMOUNT Petitioner (1) (3) Case No. Respondent (2) ATLAS No. Custodial Parent (4): Father [ ] Mother [ ] Prepared By (5): Father [ ] No. of Children (6): Mother [ ] Date Prepared (7) Father Gross Income (8) Estimated Father [ ] Mother [ ] Mother $ $ Spousal Maintenance Paid (9) $- $- Spousal Maintenance Received (10) $+ $+ Child Support Paid/Contributed (11) $- $- Support of Other Children (12) $- $- $ $ Attributed Father [ ] Mother [ ] Adjusted Gross Income (13) Combined Adjusted Gross Income (14) $ Basic Child Support Obligation (15) $ Plus Costs for: Medical/Dental/Vision Insurance (16) $ $ Childcare (17) for [ ] One Child [ ] or More Than One Child $ $ Education Expenses (18) $ $ Extraordinary Child (19) $ $ Subtotal (20) $ $ No. of Children Age 12 or Over Adj. % $ (21) Total Adjustments for Costs (22) $ Total Child Support Obligation (23) $ Each Parent's % of Combined Income (24) % % Each Parent's Share of the Total Support Obligation (25) $ $ Less Paying Parent's Costs (26) $ $ Line (15) x ______% $ $ Adjustments Subtotal (28) $ $ Preliminary Child Support Amount (29) $ $ $ $ $ $ Costs Associated with Parenting Time (27): Table A [ ] Table B [ ] No. of Days Self Support Reserve Test for Payor (30) Line (13) $ Less Paid Arrears $ Less $775 Child Support Amount to be Paid By (31): Father [ ] Mother [ ] Travel Related to Parenting Time (32) % % Medical/Dental/Vision Costs Not Paid by Insurance (33) % % Signature PARENTS WS Date 04/09 Page 1 of 1 DRS12f American LegalNet, Inc. www.FormsWorkflow.com