STATE OF NORTH CAROLINA County File No. Case No. (Code) IV-D Case No. UIFSA Case No. In The General Court Of Justice District Superior Court Division Civil: Criminal: Name Of Defendant Plaintiff STATE VERSUS WORKSHEET A CHILD SUPPORT OBLIGATION PRIMARY CUSTODY G.S. 50-13.4(c) Children Date Of Birth Children Date Of Birth Plaintiff 1. MONTHLY GROSS INCOME a. Minus pre-existing child support payment b. Minus responsibility for other children 2. MONTHLY ADJUSTED GROSS INCOME 3. PERCENTAGE SHARE OF INCOME (line 2 for each Combined to the Schedule of Basic Support Obligations see AOC-A-162, Rev. 1/15) 5. ADJUSTMENTS (expenses paid directly by each parent) $ _ _ $ % Defendant $ _ _ $ % Combined $ 4. BASIC CHILD SUPPORT OBLIGATION (apply line 2 parent's income, divided by Combined income) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ a. Work-related child care costs b. Health Insurance premium costs - child's/children's portion only (total premium � # of persons covered � # of children subject to order = children's portion) c. Extraordinary expenses d. Total Adjustments (for each column, add 5a, 5b, and 5c. 6. TOTAL CHILD SUPPORT OBLIGATION (add line 4 7. EACH PARENT'S CHILD SUPPORT OBLIGATION 8. NON-CUSTODIAL PARENT ADJUSTMENT (enter non9. RECOMMENDED CHILD SUPPORT ORDER (subtract Date Add two totals for Combined amount) Combined to line 5d Combined) (line 3 � line 6 for each parent) custodial parent's line 5d) line 8 from line 7 for the non-custodial parent only. Leave custodial parent column blank) Prepared By (type or print) (NOTE: This form may be used in both civil and criminal cases.) (Over) AOC-CV-627, Rev. 1/15 � 2015 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING CHILD SUPPORT WORKSHEET A OBLIGEE WITH SOLE CUSTODY OF CHILD(REN) Worksheet A should be used when the obligee has primary physical custody of the child(ren) who are involved in the pending action for a period of time that is more than two-thirds of the year (243 nights or more during the year). However, if the non-custodial parent's income falls within the shaded area of the Schedule, determine the basic child support obligation based on the non-custodial parent's monthly adjusted gross income, rather than the combined income of both parents, and do not proceed further on the worksheet. On line 1, enter the monthly gross incomes of both parties in the appropriate column, subtract the payments made by each parent under previous child support orders for other children of that parent and the amount of the parent's financial responsibility for other children living with that parent, and enter the difference (monthly adjusted gross income) for each parent on line 2. Add the monthly adjusted gross incomes of both parents and enter the result in the third column (Combined) on line 2. Divide each parent's monthly adjusted gross income by the combined monthly adjusted income and enter each parent's percentage share of the combined income on line 3. On line 4, enter the amount of the basic child support obligation for the child(ren) for whom support is sought by using the Schedule of Basic Child Support Obligations based on the combined income of both parents (line 3) and the number of children involved in the pending action. On lines 5a through 5c, enter the amount of work-related child care costs, health insurance premiums for the child(ren), and extraordinary child-related expenses that are paid by either parent under the column for that parent. On line 5d, enter the sum of lines 5a through 5c for each parent, and in the third column (Combined) enter the total expenses paid by both parents. Add line 4 and line 5d (Combined) and enter the result on line 6 (total child support obligation). On line 7, multiply line 6 by line 3 (percentage share of income) and enter the result in the appropriate column for eachparent. On line 8, enter the amount of expenses paid directly by the non-custodial parent (line 5d) under the appropriate column; leave the custodial parent's column blank and do not enter any amount paid by the custodial parent. Subtract line 8 from line 7 for the non-custodial parent only and enter the difference on line 9 (recommended child support order) under the column for the non-custodial parent. Leave the column for the custodial parent blank. NOTE TO PLAINTIFF AND DEFENDANT: The information required to complete the worksheet is known only to the parties. It is the responsibility of the parties to provide this information to the Court so that the Court can set the appropriate amount of child support. The Clerk of Superior Court CANNOT obtain this information or fill out this worksheet for you. If you need assistance, you may contact an attorney or apply for assistance at the IV-D agency within your county. AOC-CV-627, Side Two, Rev. 1/15 � 2015 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com