DR-25 (11/08) MONTGOMERY COUNTY DOMESTIC RELATIONS COURT CHILD SUPPORT COMPUTATION WORKSHEET SPLIT PARENTAL RIGHTS AND RESPONSIBILITIES Name of Parties ___________________________ Case No. ______________ Number of minor children ____. The following parent was designated as residential parent and legal custodian of the following number of children: ______ mother; ______ father. Father has ____ pay periods annually, Mother has ____ pay periods annually. Column I Father Column II Mother Column III Combined INCOME 1a. 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).............$________....$________ b. Amount of overtime, bonuses and commissions (Yr. 1 representing the most recent year) Father Mother Yr. 3 $_______ Yr. 3 $_________ Three years ago Yr. 2 $_______ Yr. 2 $_________ Two years ago Yr. 1 $_______ Yr. 1 $_________ Last calendar year Average $_________ $_________ (Include in Col. I and/or Col. II the average of the three years or the year 1 amount, whichever is less, if there exists a reasonable expectation that the total earnings from overtime and/or bonuses during the current calendar year will meet or exceed the amount that is the lower of the average of the three years or the year 1 amount. If, however, there exists a reasonable expectation that the total earnings from overtime/bonuses during the current calendar year will be less than the lower of the average of the 3 years or the year 1 amount, include only the amount reasonably expected to be earned this year).................................................................................$________....$________ 2. For Self-Employment Income: a. Gross receipts from business.........................................................$________....$________ b. Ordinary and necessary business expenses.................................$________....$________ c. 5.6% of adjusted gross income or the actual marginal difference between the actual rate paid by the self-employed individual and the F.I.C.A. rate.............................................................................$________....$________ d. Adjusted gross income from self-employment (Subtract the sum of 2b and 2c from 2a) ..................................................................$________....$________ 3. Annual income from interest and dividends (whether or not taxable)..........................................................................$________....$________ 4. Annual income from unemployment compensation..........................$________....$________ 5. Annual income from workers' compensation, disability insurance, or social security disability/retirement benefits..................................$________....$________ 6. Other annual income (identify) _______________________...........$________....$________ American LegalNet, Inc. www.FormsWorkflow.com Column I Father Page 2/Split Custody Worksheet Column II Mother Column III Combined 7a. Total annual gross income (add lines 1a, 1b, 2d, and 3-6)...................$________...$_______ 7b. Health Insurance maximum (multiply line 7a by 5%)….................$________...$_______ ADJUSTMENTS TO INCOME 8. Adjustment for minor children born to or adopted by either parent and another parent who are living with this parent; adjustment does not apply to stepchildren (number of children times federal income tax exemption less child support received, not to exceed federal tax exemption) ...............................$________....$________ 9. Annual court ordered support paid for other children.......................$________....$________ 10. Annual court-ordered spousal support paid to any spouse or former spouse......................................................…....................$________....$________ 11. Amount of local income taxes actually paid or estimated to be paid..$________....$________ 12. Mandatory work-related deductions such as union dues, uniform fees, etc. (not including taxes, social security, or retirement)...….....$________....$________ 13. Total gross income adjustments (add lines 8 through 12)......................$________....$________ 14a. Adjusted annual gross income (subtract line 13 from line 7a)................$________....$________ 14b. 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 for an individual, enter $0 on line 14b, Col. II. If the amount on line 7a, Col. II is 150% or higher of the federal poverty level for an individual, multiply the amount on line 14a, Col. II by 5% and enter this amount on line 14b, Col. II.)……………………………………….……..................$________....$________ 15. Combined annual income that is basis for child support order (add line 14a, Col. I and Col. II).....................................................................................................$________ 16. Percentage 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).... +________% = 100% 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 but less than another, you may calculate the difference)……...... For children for whom mother is residential parent and legal custodian $________ For children for whom father is residential parent and legal custodian $________ American LegalNet, Inc. www.FormsWorkflow.com Column I Father Page 3/Split Custody Worksheet Column II Mother Column III Combined 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. I, by line 16a) .......................... $________ b. Of mother for children for whom the father is the residential parent and legal custodian (multiply line 17, Col. II, by line 16b) ....................................... $________ 19. Annual child care expenses for the children who are the subject of this order that are work, employment training, or education Paid by related, as approved by the court or agency (deduct tax credit from father annual cost whether or not claimed)........................................................$________ Paid by mother $________ 20a. Marginal, out-of-pocket costs, necessary to provide for health insurance for the children who are the subject of this order (contributing cost of private family health insurance, minus the contributing cost of private single health insurance, divided by the total number of dependents covered by the plan, including the children subject of the support order, times the number of children subject of the support order) ....$________....$________ 20b. Cash medical support obligation (enter the amount on line 14b or the amount of annual health care expenditures estimated by the United States Department of Agriculture and described in section 3119.30 of the Revised Code, whichever amount is lower) …………………………....$________....$________ 21. ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS PROVIDED: Father Mother a. Additions: line 16a times sum of amounts shown on line 19, Col. II and line 20a, Col. II b. Additions: line 16b times sum of amounts shown on line 19, Col. I and line 20a, Col. I $ ___________ $ ___________ c. Subtractions: 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. ACTUAL ANNUAL OBLIGATION WHEN HEALTH INSURANCE IS PROVIDED : 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) ....................................................................…...…............$________ b. Any non-means-tested benefits, including social security and veterans’ benefits, paid to and received by children for whom the mother is the residential parent and legal custodian or a person on behalf of those children due to death, disability, or retirement of the father....................................................................…......….....$________ American LegalNet, Inc. www.FormsWorkflow.com Column I Father Page 4/Split Custody Worksheet Column II Column III Mother Combined c. Actual annual obligation of father (subtract line 22b from line 22a) .....................................................$________ d. Mother: line 18b plus line 21b minus line 21d (if the amount on line 21d is greater than or equal to the amount on line 21b—enter the number on line 18b in Col. II) )..........................................................................$________ 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.....................................................................................…......….....$________ f. Actual annual obligation of mother (subtract line 22e from line 22d) ...........................................................................$________ g. Actual annual obligation payable (Subtract lesser actual annual obligation using amounts in lines 22c and 22f to determine net child support payable) ............................................................$________ ...$________ 23. ADJUSTMENTS TO CHILD SUPPORT WHEN HEALTH INSURANCE IS NOT PROVIDED Father Mother a. Additions: line 16a times sum of amounts shown on line 19, Col. II and line 20b, Col. II b. Additions: line 16b times sum of amounts shown on line 19, Col. I and line 20b, Col. I $ ___________ $ ___________ c. Subtractions: line 16b times sum of amounts shown on line 19, Col. I and line 20b, Col. I d. Subtractions: line 16a times sum of amounts 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).....................................................…...........$________ b. Any non-means-tested benefits, including social security and veterans’ benefits, paid to and received by a child for whom the mother is the residential parent and legal, custodian, or a person on behalf of the child due to death, disability, or retirement of the father..…...................…...........$________ c. Actual annual obligation (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 veterans’ benefits, paid to and received by a child for whom the 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..….......................................…...........$________ f. Actual annual obligation of the mother (subtract line 24e American LegalNet, Inc. from line 24d)…………………………………………………......$________ www.FormsWorkflow.com Column I Father Page 5 Split Custody Worksheet Column II Column III Mother Combined g. Actual annual obligation payable (subtract lesser actual annual obligation from greater annual obligation of parents 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. Deviation from split residential parent guideline 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.) $________ ...$________ __________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 26. FINAL CHILD SUPPORT FIGURE (This amount WHEN HEALTH WHEN HEALTH INSURANCE IS INSURANCE IS reflects final annual child support obligation; in Col. I, PROVIDED: NOT PROVIDED: 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 in line 25)….............................................$________............$________ OBLIGOR Father Mother 27. FOR DECREE: Child support per month (Divide obligor's annual share, line 26, by 12) plus any processing charge ......................................$________.......$_________ 28. 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)………………...........................................................$_________ 29. FOR DECREE: Cash medical support per month (divide line 28 by 12)…………………………….........................................................$_________ Prepared by: Counsel: ______________________________ (For mother / father) Pro se: ______________________________ CSEA: Other: ______________________________ ______________________________ WORKSHEET HAS BEEN REVIEWED AND AGREED TO: _____________________________________ Father ____________________________________ Date _____________________________________ Mother ____________________________________ American LegalNet, Inc. Date www.FormsWorkflow.com