F 3.405N IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION _____ ______________________________ [CAPTION] vs. ______________________________ ) ) ) ) ) ) ) Case No. Document No. _____________ CHILD SUPPORT WORKSHEET OF:____________________ A. INCOME COMPUTATION-WAGE EARNER MOTHER FATHER 1. Domestic Gross Income (Insert on Line C.1. below)* INCOME COMPUTATION-SELF-EMPLOYED _______________ _______________ 1. Self-Employment Gross Income* 2. Reasonable Business Expenses (-) 3. Domestic Gross Income (Insert on Line C.1. below) _______________ _______________ _______________ _______________ _______________ _______________ C. ADJUSTMENTS TO DOMESTIC GROSS INCOME 1. Domestic Gross Income 2. Court-Ordered Child Support Paid (-) 3. Court-Ordered Maintenance Paid (-) 4. Court-Ordered Maintenance Received (+) (Insert on Line D.1. below) _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ D. COMPUTATION OF CHILD SUPPORT 1. Child Support Income _______________ +_______________ = _______________ 2. Proportionate Shares of Combined Income (Each parent's income divided by combined income) _______________%_______________% 3. Basic Child Support Obligation** (Using combined income from Line D.1., find amount for each child and enter total for all children) Age of Children 0-6 7-15 16-18 Number Per Age Category __________ __________ __________ Total Amount __________ __________ __________ = ____________ * Cost of Living Differential Adjustment? * Multiple Family Adjustment? ________ Yes _________ No ________ Yes _________ No American LegalNet, Inc. www.FormsWorkflow.com 4. Health and Dental insurance Premium MOTHER _______________ FATHER _______________ 5. Work-Related Child Care Costs (Amount x % + [.25 x (Amt. x %)] for child care credit = ________) _______________ _______________ _______________ _______________ 7. Parental Child Support Obligation (Line D.2. times Line D.6. for each parent)_______________ _______________ 6. Parents' Total Child Support Obligation (Line D.3. plus Lines D.4. and D.5) 8. Adjustment for Insurance and Child Care (Subtract for actual payment made for items _______________ D.4. and D.5.) _______________ 9. Net Parental Child Support Obligation (Obligation (Line D.7. minus Line D.8. Insert on Line F.1. below) _______________ _______________ E. CHILD SUPPORT ADJUSTMENTS APPLICABLE N/A 1. ______ 2. ______ 3. ______ 4. ______ 5. ______ 6. ______ CATEGORY _____ Long Dist. Parenting Time Costs _____ Parenting Time Adjustment _____ Income Tax Considerations _____ Special Needs _____ Agreement Past Minority _____ Overall Financial Condition 7. TOTAL (Insert on Line F.2. below) AM OUNT ALLOW ED PARENT A PARENT B (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ (+/-) __________ __________ __________ F. DEVIATION(S) FROM REBUTTABLE PRESUMPTION AMOUNT 1. Net Parental Child Support Obligation (Line D.9 from above) 2. Total Child Support Adjustments (Line E.7 above) 3. Adjusted Child Support Obligation 4. Child Support Enforcement Fee 5. *Estimated amount of arrearage ____________ 6. Monthly support towards arrearage 7. Total Monthly Support Due _________ __________ (+-) _________ (+/-) _________ _________ +________ __________ +_________ +________ _________ +_________ __________ * As shown by the records of the collecting agency. Arrearage does not include interest. American LegalNet, Inc. www.FormsWorkflow.com Attorneys are expected to check the arrearage amount with SRS for IV-D cases, and the District Court Trustee for private cases, prior to submitting this worksheet. __________________________________________ District Court Judge/Administrative Hearing Officer PREPARED AND SUBMITTED BY: ______________________________ Attorney for Respondent/Petitioner American LegalNet, Inc. www.FormsWorkflow.com