Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Child Support Computation Worksheet Split Parental Rights And Responsibilities Form. This is a Ohio form and can be use in Montgomery County (Court Of Common Pleas).
Loading PDF...
Tags: Child Support Computation Worksheet Split Parental Rights And Responsibilities, DR-25, Ohio County (Court Of Common Pleas), Montgomery
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