CHILD SUPPORT COMPUTATION WORKSHEET SOLE RESIDENTIAL PARENT OR SHARED PARENTING ORDER DATE: Name of parties and Case Number. Order Number Number of minor children The following parent was designated as residential parent and legal custodian: mother father shared Column I Father Annual gross income from employment or, when determined appropriate by the court or agency, average annual gross income from employment or a reasonable period of years. (Exclude overtime, bonuses, selfemployment income, or commissions) Amount of overtime, bonuses, and commissions (year 1 representing the most recent year) Father Mother Yr. 3 $ Yr. 3 $ (3 years ago) (3 years ago) Yr. 2 $ Yr. 2 $ (2 years ago) (2 years ago) Yr. 1 $ Yr. 1 $ (Last calendar year) (Last calendar year) (Include in Col. I and/or Col. II the average of the three years or the year 1 amount, whichever is less, if there exists a reasonable expectation that the total earnings from overtime and/or bonuses during the current calendar year will meet or exceed the amount that is the lower of the average of the three years or the year 1 amount. If, however, there exists a reasonable expectation that the total earnings from overtime/ bonuses during the current calendar year will be less than the lower of the average of the 3 years or the year 1 amount, include only the amount reasonably expected to be earned this year.) For self-employment income: Gross receipts from business Ordinary and necessary business expenses 5.6% of adjusted gross income or the actual marginal difference between the actual rate paid by the selfemployed individual and the F.I.C.A. rate Adjusted gross income from self-employment (subtract the sum of 2b and 2c from 2a) Annual income from interest and dividends (whether or not taxable) Annual income from unemployment compensation Annual income from workers' compensation, disability insurance benefits, or social security disability/retirement benefits Other annual income (identify) Total annual gross income (add lines1a, 1b, 2d, and 3-6) Health insurance maximum (multiply line 7a by 5%) Column II Mother Column III Combined INCOME: 1. a. b. $ $ 2. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ a. b. c. d. 3. 4. 5. 6. 7. a. b. DR-624 Page 1 of 5 Rev 8/13 American LegalNet, Inc. www.FormsWorkFlow.com Column I Father ADJUSTMENTS TO INCOME: 8. Adjustment for minor children born to or adopted by either parent and another parent who are living with this parent; adjustment does not apply to stepchildren (number of children times federal income tax exemption less child support received, not to exceed the federal tax exemption) Annual court-ordered support paid for other children Annual court-ordered spousal support paid to any spouse or former spouse Amount of local income taxes actually paid or estimated to be paid Mandatory work-related deductions such as union dues, uniform fees, etc. (not including taxes, social security, or retirement) Total gross income adjustments (add lines 8 ­ 12) Adjusted annual gross income (subtract line 13 from line 7a) Cash medical support maximum (If the amount on line 7a, Col. I, is under 150% of the federal poverty level for an Individual, enter $0 on line 14b, Col. I. If the amount on Line7a, Col.I, is $150% or higher of the federal poverty Level for an individual, multiply the amount on line 14a, Col. I by 5% and enter this amount on line 14b, Col. I. If The amount on line 7a, Col.II, is under 150% of the federal Column II Mother Column III Combined 9. 10. 11. 12. 13. 14. a. b. $ $ $ $ $ $ $ $ $ $ $ $ $ $ 15. 16. 17. a. b. 18. 19. a. b. Poverty level for an individual, enter $0 on line 14b, Col.II. If the amount on line 7a, Col.II, is 150% or higher of the federal poverty level for an individual, multiply the amount on line 14a, Col.II, by 5% and enter this amount on line 14b, Col.II.) $_ Combined annual income that is basis for child support order (add line 14a, Col.I and Col.II) Percentage of parent's income to total income Father (divide line 14a, Col.I, by line 15, Col.III) Mother (divide line 14a, Col.II, by line 15, Col.III) Basic combined child support obligation (refer to schedule, first column, locate the amount nearest to the amount on line 15, Col.III, then refer to column for number of children in this family. If the income of the parents is more than one sum but less than another, you may calculate the difference.) Annual support obligation per parent: Father (multiply line 17, Column III, by line 16a) $_ Mother (multiply line 17, Column III, by line 16b) Annual child care expenses for children who are the subject of this order that are work-, employment training-, or education-related, as approved by the court or agency (deduct tax credit from annual $_ cost, whether or not claimed) $_ $_ % % $_ $_ $_ DR-624 Page 2 of 5 Rev 8/13 American LegalNet, Inc. www.FormsWorkFlow.com Column I Father 20. a. Column II Mother 21. 22. 23. 24. Marginal, out-of-pocket costs, necessary to provide for health insurance for the children who are the subject of this order (contributing cost of private family health insurance, minus the contributing cost of private single health insurance, divided by the total number of dependents covered by the plan, including the children subject of the support order, times the number of children subject of the $_ support order) $_ b. Cash medical support obligation (enter the amount on line 14b or the amount of annual health care expenditures estimated by United States Department of Agriculture and described in section 3119.30 of $_ the Revised Code, whichever amount is lower) $_ ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED: Father (only if obligor or shared parenting) Mother (only if obligor or shared parenting) a. Additions: line 16a times sum of amounts shown b. Additions: line 16b times sum of amounts Line 19, Col.II and line 20a, Col.II line 19, Col.I and line 20a, Col.I $_ $_ c. Subtractions: line 16b times sum of amounts d. Subtractions: line 16a times sum of amounts shown on line 19, Col.I and line 20a, Col.I shown on line 19, Col.II and line 20a, Col.II $_ $_ OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED: a. Father: line 18a plus or minus the difference between line 21a minus line 21c $_ b. Mother: line 18b plus or minus the difference between line 21b minus line 21d $_ ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS PROVIDED: a. (Line 22a or 2