STATE OF HAWAI‘I FAMILY COURT OF THE ____________ CIRCUIT CASE NUMBER CHILD SUPPORT GUIDELINES WORKSHEET FC- NO. This document was prepared by Plaintiff Defendant Atty. for Plaintiff PLAINTIFF/PETITIONER Mother Father vs. Atty. for Defendant Name Address City, State, Zip DEFENDANT/RESPONDENT Line 1 Mother Father Telephone BASE PRIMARY SUPPORT $250 X _______ (# of children) 2 Plus Monthly Child Care Expenses + 3 Plus Monthly Health/Dental Insurance for the Child(ren) + 4 PRIMARY SUPPORT NEED (add lines 1, 2 and 3) = FATHER(A) Parents’ SOLA Income (from Table) 6 Parents’ Net SOLA Income (line 5 - line 6) 8 SOLA Percentage, 10% per child, up to 30% 9 = Less PRIMARY SUPPORT NEED (on line 4) 7 TOTAL(C) + 5 MOTHER(B) SOLA OBLIGATION (line 7 x line 8) x % 10 TOTAL SUPPORT NEED (line 4 + line 9) FATHER(A) MOTHER(B) TOTAL(C) 11 Monthly Gross Income = 12 Monthly Net Income (from Table) + 13 Income Percentage (line 12(A) ÷ line 12(C)) or (line 12(B) ÷ line 12(C)) % = % 14 Support Payable By Each Parent (line 10) x Parent’s (line 13) % 15 Less Monthly Child Care Expense for Parent Who Pays - 16 Less Monthly Health Insurance Cost for Parent Who Pays - 17 REMAINING CHILD SUPPORT PAYABLE BY EACH PARENT (Round to nearest $10.00) 18 Mother per month). Father pays to Mother Father in child support for a total of $__________ per month ($___________ per child Mother Father pays health insurance. Mother Father pays child care expenses. I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT. Father Date Mother For Court Use Only Date For exceptional circumstances see attached Exceptional Circumstance Form. For joint physical custody calculations or visitation 143 days or over per year, see Child Support Guidelines Worksheet For Joint Custody/Extensive Visitation and enter amounts on line 18 ATTACHMENT A-1 American LegalNet, Inc. www.FormsWorkflow.com