SUPERIOR COURT ,ss. Docket No. STATE OF MAINE DISTRICT COURT Location Docket No. Plaintiff CHILD SUPPORT WORKSHEET v. Defendant Supplemental Worksheet Attached M.R. Civ. P. 108(B) 19-A M.R.S. §§ 2001-2012 1. a. Primary care provider (parent children live with most of the time): Plaintiff Defendant Both If parents provide substantially equal care, higher income parent should be shown as the non-primary care provider. Plaintiff Defendant Neither b. Parent providing health insurance for the children: c. Parent providing weekly child care expenses for the children: Plaintiff Defendant Neither d. Parent providing extraordinary medical expenses for the children: Plaintiff Defendant Neither 2. Child's Name Date of Birth Child's Name Date of Birth Yearly Amounts Primary Care Provider 3. Gross income 4. Minus other obligations a. Support paid to former spouse b. Support paid for other children 5. Obligor Gross Income $ a. b. Non-Primary Care Provider Self-support reserve Below poverty level $ a. b. (Subtract lines 4a and 4b from line 3.) Combined Income 6. Other children living with non-primary care provider (See instructions on page 3.) 7. Adjusted Gross Income a. (Subtract lines 4a and 4b from b. (Subtract line 6 from line 3.) line 5.) c. (Add lines 7a and 7b.) 8. Share of Adjusted Income (Divide each parent's income by combined income) a. % b. % 9. Basic weekly support for all children up to 18 years (or up to 19 years if still in high school) (See instructions on page 3.) Total number of children (a)_____________ multiplied by amount from table (b)______________ = 9c. ________________ 0 10. Weekly health insurance cost for children Name & amount per child per week $ $ $ $ $ $ Total: FM-040-S, Rev. 0 /16 Page 1 of 3 10. 0 American LegalNet, Inc. www.FormsWorkFlow.com 11. Weekly child care expenses Name & amount per child per week $ $ $ $ $ $ Total: 11. 0 12. Extraordinary medical expenses Name & amount per child per week $ $ $ $ $ $ Total: 12. 0 *If parents provide substantially equal care, continue calculations on supplemental worksheet. 13. TOTAL WEEKLY BIWEEKLY OBLIGATION (Add lines 9c, 10, 11 and 12; if biweekly, multiply x 2) 13. _____________ 14. WEEKLY BIWEEKLY PARENTAL SUPPORT OBLIGATION: a. Primary Care Provider Spends directly $______________________ 0 (Multiply line 8a by line 13) Non-Primary Care Provider's support obligation $_______________________ 0 (Multiply line 8b by line 13) Non-Primary Care Provider Adjustments (Amounts paid directly by Non-Primary Care Provider) Weekly health insurance (line 10) -$ Weekly child care (line 11) -$ Extraordinary Medical Expenses (line 12) -$ b. Non-Primary Care Provider pays as support = $_______________________ Date: Prepared by: (Attorney for) (Plaintiff) (Defendant) (Judge)(Magistrate)(Mediator) FM-040-S, Rev. 0 /16 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com CALCULATING "AMOUNT FROM TABLE" FOR LINE 9 OF THE WORKSHEET 1. Look at the Child Support Table. 2. Circle the amount in the Table under "Parents' Combined Annual Income" that is closest to the "Combined Adjusted Gross Income" on Line 7c of the Worksheet. 3. In the "Number of Children" column, circle the TOTAL number of children in this case. Draw a line from the circled number of children down the column until it meets the circle you drew for parents' yearly combined income. Circle the number and write the number you circled in the space after "amount from table" on Line 9b of the Worksheet. 4. For example, if you have two children and a combined adjusted gross income of $18,000, use the column for 2 children. The "Parents' Combined Annual Income" and the "Number of Children" lines should meet at $54. Using this example, you would write the following on the Worksheet: 9. Total number of children 2 multiplied by amount from table $ 54 =$ 108 . NON-PRIMARY CARE PROVIDERS WITH VERY LOW INCOMES When the non-primary care provider's income is very low, different rules for calculating child support apply. If the annual gross income of the non-primary care provider is less than the federal poverty guidelines, the non-primary care provider's weekly parental support obligation may not exceed 10% of the non-primary care provider's weekly gross income, regardless of the amount of the parties' combined annual gross income. No additional amounts such as health insurance, child care, or extraordinary medical expenses should be added to this total. If the non-primary care provider's annual gross income, without adjustments, is in the self-support reserve for the total number of children for whom support is being determined, the amount listed in the self-support reserve multiplied by the number of children is the non-primary care provider's basic support obligation for the children, regardless of the parties' combined annual gross income. The non-primary care provider's proportional share of childcare, health insurance premiums, and extraordinary medical expenses is added to this basic support obligation. This paragraph does not apply if its application would result in a greater support obligation than a support obligation determined without application of this paragraph. If the non-primary care provider's income falls in the self-support reserve (the shaded area of the Child Support Table), check the box in the non-primary care provider column next to "self-support reserve" on the child support worksheet. If the non-primary care provider's income is lower than all income amounts listed in the Child Support Table, check the box next to "below poverty level" on the child support worksheet. CALCULATING AMOUNT FOR LINE 6 OF THE WORKSHEET (OTHER CHILDREN LIVING WITH NON-PRIMARY CARE PROVIDER) If the non-primary care provider has a legal obligation to support other children living in his/her home, the non-primary care provider is entitled to an adjustment. The amount of the adjustment is written on line 6. To determine the adjustment to be entered on Line 6, follow the steps in paragraphs 1, 2, 3, and 4, with some changes. In step 2, circle the amount in the Table under "Parents' Combined Adjusted Gross Income" that is closest to the non-primary care provider's gross income at Line 5. Do not circle the combined adjusted gross income of both parties in this case. In step 3, in the "Number of Children" column, circle the total number of other children living with the non-primary care provider that the non-primary care provider has a legal obligation to support. Do not circle the tot