CUYAHOGA COUNTY DOMESTIC RELATIONS COURT CHILD SUPPORT COMPUTATION WORKSHEET SPLIT PARENTAL RIGHTS AND RESPONSIBILITIES NAME OF PARTIES: _______________________________________________________ CASE NUMBER: __________________________ NUMBER OF MINOR CHILDREN: ________ NUMBER OF MINOR CHILDREN WITH MOTHER: ________ FATHER: ________ COLUMN I FATHER COLUMN II MOTHER COLUMN III COMBINED INCOME 1. a. ANNUAL GROSS INCOME FROM EMPLOYMENT OR, WHEN DETERMINED APPROPRIATE BY THE COURT OR AGENCY, AVERAGE ANNUAL GROSS INCOME FROM EMPLOYMENT OVER A REASONABLE PERIOD OF YEARS. (EXCLUDE OVERTIME, BONUSES, SELF-EMPLOYMENT INCOME , OR COMMISSIONS)...........................................…… _______________ _______________ _______________ _______________ a. GROSS RECEIPTS FROM BUSINESS.......................................... _______________ _______________ b. ORDINARY AND NECESSARY BUSINESS EXPENSES…...... _______________ _______________ c. 5.6% OF ADJUSTED GROSS INCOME OR THE ACTUAL MARGINAL DIFFERENCE BETWEEN THE ACTUAL RATE PAID BY THE SELF-EMPLOYED INDIVIDUAL AND THE F.I.C.A. RATE................................................................………... _______________ _______________ d. 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) .................….......................... _______________ _______________ b. AMOUNT OF OVERTIME, BONUSES, AND COMMISSIONS (YEAR 1 REPRESENTING THE MOST RECENT YEAR) Mother Father YR. 3 (THREE YEARS AGO) _____________ YR. 2 (TWO YEARS AGO) _____________ YR.1 (LAST CALENDAR YEAR) _____________ _____________ _____________ _____________ AVERAGE _____________ _____________ (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.).....………...... 2. 3. FOR SELF-EMPLOYMENT INCOME: DR0309121 Parental Rights and Responsibilities Child Support Computation Worksheet (Revised 03/11/2009) American LegalNet, Inc. www.FormsWorkFlow.com COLUMN I FATHER 4. COLUMN II MOTHER ANNUAL INCOME FROM UNEMPLOYMENT COMPENSATION..............................……..................................... _______________ _______________ ANNUAL INCOME FROM WORKERS’ COMPENSATION, DISABILITY INSURANCE BENEFITS, OR SOCIAL SECURITY DISABILITY/RETIREMENT BENEFITS ……......... _______________ _______________ OTHER ANNUAL INCOME (IDENTIFY).............….................... _______________ _______________ a. TOTAL ANNUAL GROSS INCOME (ADD LINES 1a, 1b, 2d AND 3-6)................................……................................................. _______________ _______________ b. HEALTH INSURANCE MAXIMUM (MULTIPLY LINE 7a BY 5%) ……………………………………………………………. _______________ _______________ ADJUSTMENTS TO INCOME 8. ADJUSTMENTS 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 THROUGH 12).........................……................................................ _______________ _______________ a. ADJUSTED ANNUAL GROSS INCOME (SUBTRACT LINE 13 FROM LINE 7).......................................................................……... _______________ _______________ b. 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 OF LINE 7a, 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.) ……… _______________ COLUMN III COMBINED _______________ 5. 6. 7. 9. 10. 11. 12. 13. 14. 15. COMBINED ANNUAL INCOME THAT IS BASIS FOR CHILD SUPPORT ORDER (ADD LINE 14, COL. I AND COL II)…........ _______________ American LegalNet, Inc. www.FormsWorkFlow.com COLUMN I FATHER 16. COLUMN III COMBINED PERCENTAGE OF PARENT’S INCOME TO TOTAL INCOME a. FATHER (DIVIDE LINE 14a, COL. I BY LINE 15, COL III) ... _____________ % b. MOTHER (DIVIDE LINE 14a, COL. II, BY LINE 15, COL. III) 17. _____________ % 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 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.).………….... FOR CHILDREN FOR WHOM MOTHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN……………………………… FOR CHILDREN FOR WHOM FATHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN……………………………… 18. _______________ _______________ _______________ ANNUAL SUPPORT OBLIGATION PER PARENT a. OF FATHER FOR WHOM MOTHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN (MULTIPLY LINE 17, COL. I, BY LINE 16a)………………………………………………. _______________ b. OF MOTHER FOR WHOM FATHER IS THE RESIDENTIAL PARENT AND LEGAL CUSTODIAN (MULTIPLY LINE 17, COL. II, BY LINE 16b)……………………………………………… 19. 20. COLUMN II MOTHER 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). a. MARGINAL, OUT OF POCKET COST, 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 THE UNITED STATES DEPARTMENT OF AGRICULTURE AND DESCRIBED IN SECTION 3119.30 OF THE REVISED CODE, WHICHEVER AMOUNT IS LOWER) ……………………………. 21. _______________ PAID BY FATHER PAID BY MOTHER _______________ _______________ PAID BY FATHER PAID BY MOTHER _______________ _______________ _______________ _______________ ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED: FATHER a. ADDITIONS: LINE 16a TIMES SUM OF AMOUNTS SHOWN ON LINE 19, COL. II AND LINE 20a, COL. II............................... c. SUBTRACTIONS: LINE 16b TIMES SUM OF AMOUNTS SHOWN ON LINE 19, COL. I AND LINE 20a, COL. I ................. _______________ _______________ American LegalNet, Inc. www.FormsWorkFlow.com COLUMN I FATHER COLUMN II MOTHER COLUMN III COMBINED MOTHER b. ADDITIONS: LINE 16b TIMES SUM OF AMOUNTS SHOWN ON LINE 19, COL. I AND LINE 20a, COL. I .............…………… d. SUBTRACTIONS: LINE 16a TIMES SUM OF AMOUNTS SHOWN ON LINE 19, COL. II AND LINE 20a, COL. II .............. 22. _______________ _______________ OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED : a. FATHER: LINE 18a PLUS LINE 21a MINUS LINE 21c (IF LINE 21c IS GREATER THAN OR EQUAL TO THE AMOUNT ON LINE 21a – ENTER THE NUMBER ON LINE 18a IN COL I)…… _______________ 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 THE FATHER (SUBTRACT LINE 22b FROM LINE 22a).......................................... _______________ d. MOTHER: LINE 18b PLUS LINE 21b MINUS LINE 21d (IF THE AMOUNT ON LINE 21d IS GREATER 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 THE 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 23. _______________ _______________ ADJUSTMENTS TO CHILD SUPPORT WHEN INSURANCE IS NOT PROVIDED: FATHER (ONLY IF OBLIGOR OR SHARED PARENTING) a. ADDITIONS: LINE 16a TIMES THE SUM OF THE AMOUNTS SHOWN ON LINE 19, COLUMN II AND LINE 20b, COLUMN II …………………………………………… _______________ c. SUBTRACTIONS: LINE 16b TIMES THE SUM OF THE AMOUNTS SHOWN ON LINE 19, COLUMN I AND LINE 20B, COLUMN I ……………………………………………………….. _______________ MOTHER (ONLY IF OBLIGOR OR SHARED PARENTING) b. ADDITIONS: LINE 16b TIMES THE SUM OF THE AMOUNTS SHOWN ON LINE 19, COLUMN I AND LINE 20b, COLUMN I _______________ d. SUBTRACTIONS: LINE 16a TIMES THE SUM OF THE AMOUNTS SHOWN ON LINE 19, COLUMN II AND LINE 20b, COLUMN II ………………………………………………………. _______________ American LegalNet, Inc. www.FormsWorkFlow.com COLUMN I FATHER 24. COLUMN II MOTHER ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS NOT PROVIDED: a. FATHER: LINE 18a PLUS LINE 23a MINUS LINE 23c (IF THE AMOUNT ON LINE 22c 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 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 (SUBTRACT LINE 24b FROM LINE 24a) ………………………………………………… _______________ d. MOTHER: LINE 18b PLUS LINE 21b 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 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 THE MOTHER (SUBTRACT LINE 24e FROM LINE 24d)........................................ _______________ g. ACTUAL ANNUAL OBLIGATION PAYABLE (SUBTRACT LESSER ACTUAL ANNUAL OBLIGATION FROM GREATER ACTUAL ANNUAL OBLIGATION USING AMOUNTS IN LINES 24c AND 24f TO DETERMINE NET CHILD SUPPORT PAYABLE)…………………………………………………………. _______________ _______________ h. ADD LINE 20b, COL. I, TO LINE 24g, COL. I, WHEN FATHER IS THE OBLIGOR OR LINE 20b, COL. II, TO LINE 24g, COL. II WHEN MOTHER IS OBLIGOR…………………………………... 25. COLUMN III COMBINED _______________ _______________ a. DEVIATION FROM SPLIT RESIDENTIAL GUIDELINE AMOUNT SHOWN ON LINE 22c, 22f, 24c, OR 24f IF MOUNT WOULD BE UNJUST OR INAPPROPRIATE: (SEE SECTION 3119.23 OF THE REVISED CODE.) (SPECIFIC FACTS AND MONETARY VALUE MUST BE STATED.) ______________________________________________________ ______________________________________________________ ______________________________________________________ ADJUSTMENT (+/-) OF FATHER _______________ ADJUSTMENT (+/-) OF MOTHER _______________ WHEN HEALTH INSURANCE IS PROVIDED: 26. FINAL CHILD SUPPORT FIGURE (THIS AMOUNT REFLECTS FINAL ANNUAL CHILD SUPPORT OBLIGATION; IN COL. I, ENTER LINE 22c PLUS OR MINUS ANY AMOUNTS INDICATED IN LINE 25a OR IN COL. II, ENTER LINE 24g PLUS OR MINUS ANY AMOUNTS INDICATED IN LINE 25) …………………………….…………… $ _____________ WHEN HEALTH INSURANCE IS NOT PROVIDED: $ _____________ FATHER MOTHER OBLIGOR American LegalNet, Inc. www.FormsWorkFlow.com WHEN HEALTH INSURANCE IS PROVIDED: 27. 28. 29. FOR DECREE CHILD SUPPORT PER MONTH (DIVIDE OBLIGOR’S ANNUAL SHARE, LINE 26 BY 12) PLUS ANY PROCESSING CHARGES ………………………………………………………. $ _____________ 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) …………... WHEN HEALTH INSURANCE IS NOT PROVIDED: $ _____________ FATHER MOTHER OBLIGOR $ _____________ FOR DECREE CASH MEDICAL SUPPORT PER MONTH (DIVIDE LINE 28 BY 12) ……………………………………………………………. $ _____________ PREPARED BY: COUNSEL: ________________________________________ (FOR FATHER/MOTHER) PRO SE: _______________________________________ CSEA: ____________________________________________ OTHER: _______________________________________ WORKSHEET HAS BEEN REVIEWED AND AGREED TO: ____________________________________________________ MOTHER _______________________________________________ DATE ____________________________________________________ FATHER _______________________________________________ DATE American LegalNet, Inc. www.FormsWorkFlow.com