STATE OF HAWAI'I FAMILY COURT OF THE ___________ CIRCUIT EXCEPTIONAL CIRCUMSTANCES FORM to be attached to CHILD SUPPORT GUIDELINES WORKSHEET (CSGW) CASE NUMBER: FC-__ No. __________ This form requires information from your completed CSGW, and you must mark it as an attachment at the bottom of the CSGW. Payor Parent: No. of children in this case: CS amount from Line 14: The court should deviate from the Total Monthly Child Support Obligation as calculated on Line 14 of the Child Support Guidelines Worksheet (CSGW) because of the following exceptional circumstance(s): EXCEPTION REQUESTED BECAUSE CALCULATED CHILD SUPPORT EXCEEDS 70% OF NET INCOME Payor's total monthly child support obligation as calculated on Line 14 of the CSGW (___________) exceeds the minimum support amount of $70 per child and is greater than 70% of Payor's net income from the Table of Incomes (___________). I request a finding that an exceptional circumstance exists and that Payor's total monthly child support obligation on Line 14 of the CSGW be limited to either 70% of Payor's net income or $70 per child, whichever is greater. Using the higher of the two numbers the total support for the ___ children in this case would be ___________ per month. After deductions for monthly child care expenses listed on Line 15 (________) and health insurance costs listed on Line 16 (________), which are paid directly by Payor, the remaining child support obligation of Payor will be ___________ per month ADDITIONAL LEGAL CHILD(REN) EXCEPTION REQUESTED BECAUSE PAYOR SUPPORTS A) Payor's total monthly child support obligation as calculated on Line 14 of the CSGW (___________), divided by the number of children to be supported on Line 4 of the CSGW (___), equals ___________ per child. Is this amount per child greater than $70 per child (the minimum support amount)? Yes No B) Payor supports ___ additional legal child(ren). If all of Payor's Net Income on Line 2 of the CSGW (___________) is divided by the total number of children Payor is required to support (___), each child would receive ___________. Is this amount per child less than the amount per child calculated on Line (A)? Yes No If the answers to both questions above is 'Yes,' you may request that the Court make the following finding: Due to Payor's obligation to support (and Payor's actual support of) additional children, I request a finding that an exceptional circumstance exists and that the support per child in this case be limited to the greater of the amount per child shown in Line (B) above, ___________, or the State minimum per child of $70. Using the higher of the two numbers the total support for the ___ children in this case would be ___________ per month. After deductions for monthly child care expense listed on Line 15 (________) and health insurance/cash medical cost listed on Line 16 (________), which are paid directly by Payor, the remaining child support obligation of Payor will be ___________ per month. EXCEPTION REQUESTED DUE TO OTHER CIRCUMSTANCES SUMMARY OF CHILD SUPPORT PAYMENTS (IF EXCEPTION IS GRANTED) Mother Father pays monthly child support of to other parent, Mother Father pays health insurance/cash medical. Mother per child per mo. Father pays child care expense. American LegalNet, Inc. www.FormsWorkFlow.com