JD-FM-220 (New 3-12) CCSG-1 Rev. 8-05 C.G.S. §46b-215a STATE OF CONNECTICUT COMMISSION FOR CHILD SUPPORT GUIDELINES §46b-215a-5b, Regulations of Connecticut State Agencies WORKSHEET for the Connecticut Child Support and Arrearage Guidelines MOTHER FATHER CUSTODIAN MOTHER COURT FATHER OTHER: D.N./CASE NO. CHILD’S NAME DATE OF BIRTH CHILD’S NAME NUMBER OF CHILDREN DATE OF BIRTH CHILD’S NAME DATE OF BIRTH All money amounts in this worksheet may be rounded to the nearest dollar I. NET INCOME (Weekly amounts) 1. MOTHER Gross income (attach verification) 1a. FATHER $ $ Number of hours used in calculation 2. Federal income tax (based on all allowable exemptions, deductions and credits) $ $ 3. Social security tax or mandatory retirement $ $ 4. Medicare tax $ $ 5. State and local income tax (based on all allowable exemptions, deductions and credits) $ $ 6. Medical/hospital/dental insurance premiums (including Husky) for parent and all legal dependents $ $ 7. Court-ordered life insurance for benefit of child $ $ 8. Court-ordered disability insurance $ $ 9. Mandatory union dues or fees (if deducted by employer) $ $ 10. Mandatory uniforms and tools (if deducted by employer) $ $ 11. Non-arrearage payments on court-ordered alimony and child support awards (for other than child) $ $ 12. Imputed support obligation for qualified child (line 12d below times the number of qualified children) MOTHER FATHER $ $ Number of qualified children 12a. Sum of lines 2-11 $ $ 12b. Line 1 minus line 12a $ $ 12c. Current support amount for the parent’s qualified children plus all children for whom support is being determined (based on line 12b for claiming parent only) $ $ 12d. Line 12c divided by number of children used in line 12c $ $ 13. Sum of lines 2-12 $ $ 14. Net income (line 1 minus line 13) $ $ II. CURRENT SUPPORT 15. Combined net weekly income (rounded to the nearest $10) $ 16. Basic child support obligation (from Schedule of Basic Child Support Obligations) $ 17. Each parent’s percentage share of line 15 (line 14 for each parent divided by line 15, times 100%) % % (If noncustodial parent is a low-income obligor, skip this line and enter line 16 amount in noncustodial parent’s column on line 18.) 18. Each parent’s share of the basic child support obligation (line 17 times line 16 for each parent) $ $ 19. Social security dependency benefits adjustment $ $ 20. Presumptive current support amounts (line 18 minus line 19) (Rounded to the nearest dollar) (Enter noncustodial parent’s amount on line 34, unless deviation criteria apply – see section VII.) $ $ CONTINUED ON REVERSE American LegalNet, Inc. www.FormsWorkFlow.com ,,, 1(7 ',6326$%/( ,1&20( 027+(5   $PRXQW RI ZHHNO\ DOLPRQ\ LI DQ\  /LQH  WLPHV   /LQH  SOXV OLQH  (for recipient of alimony) OLQH  PLQXV OLQH  (for payer of alimony)  1RQFXVWRGLDO SDUHQW¶V OLQH  DPRXQW VRFLDO VHFXULW\ GHSHQGHQF\ EHQHILWV IRU FKLOG  )$7+(5 /LQH  SOXV OLQH  (for custodial parent) OLQH  PLQXV OLQH  (for noncustodial parent) /LQH  SOXV OLQH  (for custodial parent) OLQH  PLQXV OLQH  (for noncustodial parent) paid by QRQFXVWRGLDO SDUHQW FXVWRGLDO SDUHQW ,9 815(,0%856(' 0(',&$/ (;3(16(  6XP RI OLQH  DPRXQWV FRPELQHG QHW GLVSRVDEOH LQFRPH  (DFK SDUHQW¶V SHUFHQWDJH VKDUH RI FRPELQHG QHW GLVSRVDEOH LQFRPH OLQH  IRU HDFK SDUHQW GLYLGHG E\ OLQH  WLPHV   URXQGHG WR WKH QHDUHVW ZKROH SHUFHQWDJH If the noncustodial parent is a low-income obligor, proceed to line 29. If the noncustodial parent is not a low-income obligor, enter these percentages on line 35, unless deviation criteria apply.  8QOHVV GHYLDWLRQ FULWHULD DSSO\ HQWHU RQ OLQH  IRU WKH QRQFXVWRGLDO SDUHQW WKH OHVVHU RI WKH QRQFXVWRGLDO SDUHQW¶V OLQH  SHUFHQWDJH RU   DQG HQWHU RQ OLQH  IRU WKH FXVWRGLDO SDUHQW  PLQXV WKH SHUFHQWDJH HQWHUHG IRU WKH QRQFXVWRGLDO SDUHQW 9 &+,/' &$5( &2175,%87,21  'HWHUPLQH LI WKH QRQFXVWRGLDO SDUHQW¶V OLQH  DPRXQW IDOOV ZLWKLQ WKH GDUNHU VKDGHG DUHD RI WKH VFKHGXOH ,I LW GRHV SURFHHG WR OLQH  ,I LW GRHV QRW VNLS OLQH  DQG HQWHU WKH QRQFXVWRGLDO SDUHQW¶V OLQH  SHUFHQWDJH RQ OLQH  XQOHVV GHYLDWLRQ FULWHULD DSSO\  'HWHUPLQH LI WKH FXVWRGLDO SDUHQW¶V OLQH  DPRXQW IDOOV ZLWKLQ WKH GDUNHU VKDGHG DUHD RI WKH VFKHGXOH ,I LW GRHV QRW HQWHU  RQ OLQH  DV WKH QRQFXVWRGLDO SDUHQW¶V FKLOG FDUH FRQWULEXWLRQ XQOHVV GHYLDWLRQ FULWHULD DSSO\ ,I LW GRHV HQWHU RQ OLQH  WKH OHVVHU RI WKH QRQFXVWRGLDO SDUHQW¶V OLQH  SHUFHQWDJH RU   XQOHVV GHYLDWLRQ FULWHULD DSSO\ 9, $55($5$*( 3$