State of Tennessee – Child Support Worksheet Part I. Identification PRP ARP SPLIT Name of Mother: Name of Father: Name of non-parent Caretaker: TCSES case #: Docket #: Court name: Indicate the status of each parent or caretaker by placing an “X” in the appropriate column Name(s) of Child(ren) Days with Mother Days with Father Days with Caretaker Column A Date of Birth Column B Column C Part II. Basic Support Obligation ü ü 1 Use Credit Worksheet to calculate line items 1b – 1d 2 3 4 For clarity and consistency, use Column A for PRP information and Column B for ARP information For Split Parenting, use Column A for Mother’s information and Column B for Father’s information Monthly Gross Income 1a Self-employment tax paid 1b Credit for pre-existing support orders 1c Credit for In Home Children 1d Credit for Not In Home Children Adjusted Gross Income (AGI) Percentage Share of Income (PI) Basic Child Support Obligation (BCSO) $ $ $ $ % $ % % $ Part III. Parents’ Share of Support Obligation Standard Parenting 5 Each parent’s share of the BCSO Split Parenting 6a Mother’s obligation for children for whom father is the PRP Father’s obligation for children for whom mother is the PRP 6b $ $ $ $ Part IV. Parenting Time Adjustment 7a 7b 8a 8b 9 10 Number of days per calendar year with children supported by this order with whom the ARP spends 121 or more days per calendar year Parenting time adjustment percentage Number of days per calendar year with children supported by this order with whom the ARP spends 53 or fewer days per calendar year Parenting time adjustment percentage Adjustment in ARP's support obligation for parenting time Each parent's share of the adjusted BCSO % % % % $ $ $ $ 11-4-04 American LegalNet, Inc. www.USCourtForms.com State of Tennessee – Child Support Worksheet Part V. Additional Expenses Column A Column B 11a 11b 11c 12 Children’s portion of health insurance premium Work-related childcare Total additional expenses Each parent's share of additional expenses $ $ $ $ $ $ $ $ 13 14 Adjusted Support Obligation (ASO) Enter amount of payroll deduction from lines 11a and/or 11b or direct payments made from line 11a. Subtract line 14 from line 13. Enter remainder. $ $ $ Column C $ 15 $ Part VI. Presumptive Child Support Order / Modification of Current Support Obligation Column 16 Presumptive Child Support Order (PCSO) $ The ARP’s amount from Line 15* * For split parenting, enter the difference between the greater and smaller numbers from Line 15 Modification of Current 17a Current child support order amount for the payor parent $ Child Support Order 17b Amount required for significant variance to exist $ 17c Actual variance between current and presumptive child support orders $ Part VII. Uninsured Medical Expenses, Deviations, Final Child Support Order 18 Uninsured Medical Expenses (recurring): $ 19 Deviations (Specify): $ 20 Final Child Support Order $ Deviations must be Substantiated by written findings in the Child Support Order Comments, Calculations, or Rebuttals to Schedule Place an “X” in the Has the tribunal identified a parent as a low-income provider? appropriate blank Yes No Preparer’s Use Only Name: Date: Title: IV-D Use Only 21a Child Support Obligation $ 21b Medical Support Obligation $ 11-4-04 American LegalNet, Inc. www.USCourtForms.com