COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION CLERMONT COUNTY, OHIO CHILD SUPPORT WORKSHEET INFORMATION NAME OF PERSON COMPLETING THIS FORM: Case Number: I. YOUR WAGES (if self-employed, skip to Section II below) Annual gross wages: $ Other income: $ Overtime/bonuses/commissions for the most recent three years: Last year: $ Two years ago: $ Three years ago: $ II.YOUR SELF-EMPLOYMENT INCOME (If you receive a Form W-2, complete Section I above rather than this section)Gross yearly receipts:$ Ordinary and necessary business expenses:$ III.ADJUSTMENTS TO INCOME A. Number of minor children NOT A PART OF THIS CASE who were born to you or adoptedby you (NOTE: this does NOT include stepchildren): B. Do the children included in Section A above reside with you? Yes No C. Court-ordered support you receive for minor children included in Section A above $ YEARLY D. Court-ordered support you pay for the minor children included in Section A above $ YEARLY E. Local taxes you actually pay to a city/township/county Name of city/township/county Percentage rate of tax % F. Mandatory work-related amounts you pay such as union dues, uniform fees, etc. (not including social security or retirement) $ YEARLY G. Child care expenses YOU pay for children IN THIS CASE while you work, obtain training or go to school (Do NOT include day care paid by the other parent) $ YEARLY IV.HEALTH INSURANCE INFORMATION Name of Insurer: Policy #: I, ( ame), certify that the information I have provided with regard to preparation of a CHILD SUPPORT WORKSHEET is true and accurate to the best of my knowledge: Date: Signature DR-626 Rev. American LegalNet, Inc. www.FormsWorkFlow.com