Child Support Computation Worksheet Split Parental Rights and Responsibilities Date Name of Parties Case No. -. .... . - ... ..... . . . . .............. and ..... . . . ....-- Order No. . ......... - Number of Minor Children Number of Children with Mother Number of Children with Father Column I Father Column 1 1 Mother Column 111 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 cornrnissions) b. Amount of overtime, bonuses, and commissions (year I representing the most recent year) Father Yr. 3 $ . (Three years ago) Yr. 2 $ (Two years ago) Yr. I $ _ (Last Calendar Year) Average $ Mother Yr. 3 $ (Three years ago) Yr. 2 $. -(Two years ago) Yr. 1 $ (Last Calendar Year) Average $ $ _- -- _ $ .... - .......... $ ...... $ (Include in Col. I and/or Col. 11 the average of the three years or the year I amount. whichever is less. if there exists a reasonable exwectation that the total earnings from overtilne andlor bonuses during the chrrent calendar year will meet or exceed the amount that is the lower of the average of the three years or the year I amount. If, however, there exists a reasonable expectation that the total earnings from overtimdbonuses during the current calendar year will be less than the lower of the average of the three years or the year I amount, include only the amount reasonably expected to be earned this year.) 2. For self-employment income 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) 3. 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 disabilitylretirement benefits Other annual income (identify) $-- - -.-. -- - $ 4. 5. 6. 7. a. Total annual gross income (add lines la, 1 b, 2d, and 3-6) b. Health insurance maximum (multiply line 7a by 5%) 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) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 5 Child Support Computation Worksheet Split Parental Rights and Responsibilities Date Name of Parties Case No. Number of Minor Children Number of Children with Mother Number of Children with Father Column 1 Father 9. 10. Annual court-ordered support paid for other children Annual court-ordered spousal support paid to any spouse or former spouse Column I1 Mother Column I11 Combined and Order No. A 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) 13. Total gross income adjustments (add lines 8 through 12) 14. a. Adjusted annual gross income (subtract line 13 from line 7a) 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 on 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. 1. If the amount on line 7a, Col. 11, is under 150% of the federal poverty level for an individual, enter $0 on line 14b, Col. 11. If the amount on line 7a, Col. 11, is 150% or higher of the federal poverty level for an individual, multiply the amount on line 14a, Col. 11, by 5% and enter this amount on line 14b, Col. 11.) 15. 16. Combined annual income that is basis for child support order (add line 14a, Col. I and Col. 11) Percentage of parent's income to total income a. Father (divide line 14a, Col. I, by line 15, Col. 111) b. Mother (divide line 14a, Col. 11, by line 15, Col. 111) 17. Basic combined child support obligation (refer to schedule, first column, locate the amount nearest to the amount on line 15, Col. 111, then refer to column for number of children with this parent. If the income of the parents is more than one sum but less than another, you may calculate the difference) For children for whom the Mother is Residential Parent and Legal Custodian. For children for whom the Father is Residential Parent and Legal Custodian. I I. 12. 18. Annual support obligation per parent a. Of father for children for whom mother is the residential parent and legal custodian (multiply line 17, Col. 1, by line 16a) b. Of mother for children for whom the father is the residential parent and legal custodian (multiply line 17, Col. 11, by line 16b) 19. 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) Paid by father Paid by mother 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, 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 3 1 19.30 of the Revised Code, whichever amount is lower) Paid by father Paid by mother $ $ .. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 Child Support Computation Worksheet Split Parental Rights and Responsibilities Date Name of Parties Case No. Number of Minor Children .... ... -- ....... - . . - -.. - .. and .............. ............. -.-- Order No. .................... ~ Number of Children with Mother Number of Children with Father Column I Father Column I1 Mother Column 111 Combined 21. A