FC-78 (revised December 2017) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT CHILD SUPPORT GUIDELINE WORKSHEET Plaintiff Civil Action File Number Defendant To be filed with complaints for divorce, for divorce on bed and board, miscellaneous complaints, and when an answer or modification is filed. Number of children: Plaintiff Defendant Combined 1. Monthly Gross Income $ $ XXX 2. Required Deductions: - - a. Preexisting Child Support Payments - - XXX b. Health Insurance Premiums or Medical Cash Contributions - - XXX c. Additional Minor Dependents - - XXX d. Work Related Child Care Cost Share - - XXX 3. Optional Adjustments in the Discretion of the Court a. Pension/Retirement Payments - - XXX b. Life Insurance Premium Payments - - XXX c. Parent's Extraordinary Medical Expenses - - XXX d. Income Tax Exemptions Adjustment +/- +/- XXX e. Payments of Assigned Marital Debts - - XXX 4. Monthly Adjusted Gross Income (line 1 minus lines 2 and 3) $ $ $ 5. Percentage Share of Income (line 4 income divided by line 4 combined income) 100% 6. Basic Child Support Obligation (apply line 4 combined income to child support table) XXX XXX 7. Work-Related Child Care Costs (actual costs minus federal tax credit) XXX XXX 8. Total Child Support Obligation (add lines 6 and 7) XXX XXX $ 9. Parent's Child Support Obligation (for each parent, line 5 percentage X line 8) $ $ XXX 10. Recommended Child Support Order (enter line 9 amount for non-custodial parent only; leave other column blank) $ $ XXX 11. Basic Child Support Amount Ordered: $ per weekly/bi-weekly/monthly 12. Cash Medical Ordered: $ per weekly/bi-weekly/monthly 13. TOTAL AMOUNT ORDERED: $ per (add lines 11 and 12) weekly/bi-weekly/monthly Prepared and presented By/for the plaintiff Date By/for the defendant Date Prepared and presented by the Office of Child Support Services (if applicable): Date: Entered as an Order of the court on . APPROVED : /s/ Judicial Officer American LegalNet, Inc. www.FormsWorkFlow.com