CHILD SUPPORT COMPUTATION WORKSHEET SPLIT PARENTAL RIGHTS AND RESPONSIBILITIES DATE:________________ Name of parties ___________________________ and ______________________________ Case No. _________________ Order No. _________________ Number of minor children _____ The following parent was designated as residential parent and legal custodian: □ mother □ father □ shared Column I Father INCOME: 1. a. b. 2. a. b. c. d. 3. 4. 5. 6. 7. a. b. 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 $_______ $_______ $_______ $_______ $_______ $_______ $_______ Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Column I Column II Column III Father Mother Combined ADJUSTMENTS TO INCOME: 8. 9. 10. 11. 12. 13. 14. a. b. 15. 16. a. b. 17. 18. a. b. 19. 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 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 For children For children schedule, first column, locate the amount nearest to for whom for whom the amount on line 15, Col.III, then refer to column for the mother the father number of children in this family. If the income of the is the is the parents is more than one sum but less than another, residential residential you may calculate the difference.) parent and parent and legal custodian legal custodian $_______ $_______ Annual support obligation per parent: Of father for children for whom mother is the residential parent and legal custodian (multiply line 17, Column I, by line 16a) $_______ Of mother for children for whom the father is the residential parent and legal custodian (multiply line 17, Column II, 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 Paid by father Paid by mother court or agency (deduct tax credit from annual $_______ $_______ cost, whether or not claimed) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Column I Father Column II Mother Column III Combined 20. a. 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, Paid by father Paid by mother 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) $_______ $_______ 21. 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 $____________ $__________ 22. ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS PROVIDED: a. Father: line 18a plus line 21c (if the amount on line 21c is greater than or equal to the amount on line 21a, enter the number on line 18a in Col. $_______ b. Any non-means-tested benefits, including social security and veterans’ benefits, paid to and received by children for whom the mother is the residential parent and legal custodian or a person on behalf of those children due to death, disability, or retirement of the father $_______ c. Actual annual obligation of father (subtract line 22b from line 22a) $_______ d. Mother (Line 18b plus line 21b minus line 21d (if the amount on line 21d is greather than or equal to the amount on line 21b, enter the number on line 18b in Col. II) $_______ e. Any non-means-tested benefits, including social security and veterans’ benefits, paid to and received by children for whom the father is the residential parent and legal custodian or a person on behalf of those children due to death, disability, or retirement of the mother $_______ f. Actual annual obligation of mother (subtract line 22e from line 22d) $_______ g. Actual annual obligation payable (subtract lesser actual annual obligation from greater actual annual obligation using amounts in lines 22c and 22f to determine net child support payable) $_______ $_______ Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Column I Father Column II Mother Column III Combined 23. ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS NOT 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 on line 19, Col.II and line 20b, Col.II line 19, Col.I and line 20b, 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 20b, Col.I shown on line 19, Col.II and line 20b, Col.II $____________ $__________ 24. ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS NOT PROVIDED: a. Father: line 18a plus line 23a minus line 23c (if the amount on line 23c is greater than or Equal to the amount on line 23a, enter the Number on line 18a in Col. I) $_______ b. Any non-means-tested benefits, including social security and veteran’s benefits, paid to and received by a child for whom mother is the residential parent and legal custodian, or a person on behalf of the child, due to death, disability or retirement of the father $_______ c. Actual annual obligation of the father (subtract line 24b from line 24a) $_______ d. Mother: line 18b plus line 23b minus line 23d (if the amount on line 23d is greater than or equal To the amount on line 23b, enter the number On line 18b in Col. II) $_______ e. Any non-means-tested benefits, including social security and veteran’s benefits, paid to and received by a child for whom father is the residential parent and legal custodian, or a person on behalf of the child, due to death, disability or retirement of the mother $_______ f. Actual annual obligation of the mother (subtract Line 24e from 24d) $_______ g. Actual annual obligation payable (subtract lesser Actual obligation from greater annual obligation of Parents using amounts in lines 24c and 24f to Determine net child support payable) $_______ $_______ 25. Deviation from split residential parent support amount shown on line 22c, 22f, 24c, or 24f if amount would be unjust or inappropriate: (see section 3119.23 of the Revised Code.) (Specific facts and monetary value must be stated.) _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com WHEN HEALTH INSURANCE IS PROVIDED 26. 27. 28. 29. FINAL CHILD SUPPORT FIGURE: (This amount reflects Final annual child support obligation; in column I, Enter line 22g plus or minus any amounts indicated in line 25, or in Col.II, enter line 24g plus or minus any amounts indicated on line 25) $_______ FOR DECREE: Child support per month (divide obligor’s Annual share, line 26, by 12) plus any processing Charge $_______ FINAL CASH MEDICAL SUPPORT FIGURE: (this Amount reflects the final, annual cash medical support to be paid by the obligor when neither parent provides health insurance coverage for the child; enter obligor’s cash medical support amount from line 20b) FOR DECREE: Cash medical support per month (divide Line 28 by 12) plus any processing charge WHEN HEALTH INSURANCE IS NOT PROVIDED $_______ Father/Mother, OBLIGOR $_______ $_______ $_______ Prepared by: Counsel:________________________________ (For mother/father) Pro se: _____________________________ CSEA: _____________________________ Other: ______________________________ Worksheet has been reviewed and Agreed to: _______________________________________ Mother _________________ Date _______________________________________ Father _________________ Date 3/2009 Form DR-625 (7769) Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com