DR 7.6(A) (Revised 04/03//2017) Page 1 CHILD SUPPORT COMPUTATION WORKSHEET SPLIT PARENTAL RIGHTS AND RESPONSIBILITIES Name of Parties Case No. A/DR File No. Number of minor children: Number of minor children with mother: father: COLUMN I COLUMN II COLUMN III INCOME FATHER MOTHER COMBINED 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 )205205205 $ $ 1.b Amount of overtime, bonuses and commissions:( year 1 representing the most recent year ) YR 3 Three Years Ago YR 3 Three Years Ago $ $ YR 2 Two Years Ago YR 2 Two Years Ago $ $ YR 1 Last Calendar Year YR 1 Last Calendar Year $ $ AVERAGE $ $ (Include in Column I and/or Column 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.)205205205205205205205205205205205205205 $ $ 2. For self-employment income: a. Gross receipts from business205205205205205205205205205205205205205205205205205205205205205205 $ $ b. Ordinary and necessary business expenses205205205205205..205205205205205205205205205205 $ $ 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. 205205205205205205 $ $ 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 )205205205205205205 $ $ 4. Annual employment from unemployment compensation205205205.205205205205205205205205. $ $ 5. Annual income from workers' compensation, disability insurance benefits, or social security disability/retirement benefits205205..205205205205205205205205205. $ $ 6. Other annual income ( identify )205205205205205205205205.205205205205205205205205205205205205205205 $ $ 7.a. Total annual gross income ( add lines 1a, 1b, 2d, and 3-6 )205205205205205205205205205205 $ $ b. Health insurance maximun (multiply 7a by 5%) 205205205205205205205205205205205205205205205 $ $ 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 )..........................205205205205205205205205205205205205205205205205205 $ $ 9. Annual court-ordered support paid for other children205205205205205205205205205205205205205. $ $ 10. Annual court-ordered spousal support paid to any spouse or former spouse. 205205 $ $ 11. Amount of local income taxes actually paid or estimated to be paid. 205205205205205205. $ $ 12. Mandatory work-related deductions such as union dues, uniform fees, etc. ( not including taxes, social security, or retirement )205205205205205205205205205205205205205205 $ $ 13. Total gross income adjustments ( add lines 8 through 12 )205205205205205205205205205205205 $ $ 14.a. Adjusted annual gross income ( subtract line 13 from line 7 ) 205205205205205205205205205.. $ $ 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. I. If the amount on line 7a, Col. II, is under 150% of the federal poverty level level for an individual, enter $0 on line 14b, Col. II. If the amount on line 7a, Col. II, is 150% 150% of poverty or higher of the federal poverty level for an individual, multiply the amount on line 14a, Level Col. II, by 5% and enter this amount on line 14b, Col. II.)205205205205205205205205205205205205. $ $ $18,090.00 15. Combined annual income that is basis for child support order ( add line 14, Col. I and Col. II )205205205205205205205205205205205...205205205205205205...205205205205 $ 16. Percentage of parent's income to total income: a. Father ( divide line 14, Col. I by line 15, Col. III )205205205205205205205205205205205205205205 % b. Mother ( divide line 14, Col. II by line 15, Col. III )205205205205205205205205205205205205205. % American LegalNet, Inc. www.FormsWorkFlow.com DR 7.6(A) (Revised 04/03//2017) Page 2 COLUMN I COLUMN II COLUMN III FATHER MOTHER COMBINED 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 for number of children with this parent. If the income of the parents is more than one sum and less than another, you may calculate the difference.) For children for whom the mother is the residential parent and legal custodian 205 $ For children for whom the father is the residential parent and legal custodian 205205 $ 18. Annual support obligation per parent a. Of father for children for whom mother is residential parent and legal custodian ( multiply line 17, Col. I, by line 16a )205205205205205205205205205205205205205205205205205205205 $ a. Of mother for children for whom father is residential parent and legal custodian ( multiply line 17, Col. II, by line 16b )205205205205205205205205205205205205205205205205205205. $ 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 )205205205.. $ $ before tax credit $ $ after tax credit 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 Paid by father Paid by mother of children subject of the support order)205205205205205205205..205..205205205205205205205205205205.. $ $ b. Cash medical support obligation (enter the amount on line 14b or the amount of annual USDA estimate of health care expenditures estimated by the United States Department of Agriculture annual health care expense and described in section 3119.30 of the Revised Code, $ whichever amount is lower)205205205205205205205205205205205205205205205. $ $ ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED 21. Father Mother a. Additions: Line 16a times sum of amounts shown on line 19, Col. II and line 20, Col. II205205205205205205205205205205205205205205.. $ Mother b. Additions: Line 16b times sum of amounts shown on line 19, Col. I and line 20, Col. I205205205205205.205.. $ c. Subtractions: Line 16b times sum of amounts shown on line 19, Col. I and line 20, Col. I205205205205205205205205205205205205205205205 $ d. Subtractions: Line 16a times sum of amounts shown on line 19, Col. II and line 20, Col. II205205205205205205. $ ACTUAL ANNUAL OBLIGATION 22. a. Father: line 18a plus line 21a minus 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. I )205 $ 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 father205205205205205205205205205205205205205205205205205205205205205205 $ c. Actual annual obligati