CHILD SUPPORT GUIDELI NES WORKSHEET Case No.: ........................................................................ .......................................................... Commonwealth of Virginia Va. Code 20-108.2 ........................................................................ ....................................................................... v. ........................................................................ ............................................................. ........................................................................ ... D ATE MOTHER FATHER 1. Monthly Gross Income (see instructions on reverse) $ .......................................... $ ................................................ 2. Adjustments for spousal support payments (see instructions on reverse) $ .......................................... $.................................................. 3. Adjustments for support of child(ren) (see instructions on reverse) $ .......................................... $.................................................. 4. Deductions from Monthly Gross Income allowable by law -$............................................ -$.................................................. (see instructions on reverse) 5. a. Available monthly income $ .......................................... $ ................................................ b. Combined monthly available income (combine both available monthly income figures from line 5.a.) $ 6. Number of children in the present case for whom support is sought: 7. a. Monthly basic child support obligation (from schedule see instructions on reverse) a. $..................................................... b. Monthly amount allowable for health care coverage b. $..................................................... (see instructions on reverse) c. Monthly amount allowable for employment-related child care expenses c. $..................................................... (see instructions on reverse) 8. Total monthly child support obligation (add lines 7.a., 7.b., and 7.c.) $ MOTHER FATHER 9. Percent obligation of each party (divide available monthly income on ...............................................% ...............................................% line 5.a. by line 5.b.) 10. Monthly child support obligation of each party (multiply line 8 by line 9) $ $ 11. Deduction by non-custodial parent for health care coverage when paid directly by non-custodial parent (from line 7.b.) $ .......................................... $ .......................................... MOTHER FATHER 12. Adjustments (if any) to Child Support Guidelines Calculation (see instructions on reverse) a. Credit for benefits received by or for the child derived from the parents -$........................................... -$................................................ entitlement to disability insurance benefits to the extent that such derivative benefits are included in a parents gross income b. ........................................................................ ............................................................................................................................ $............................................ $............................................... c. ........................................................................ ........................................................................................................................... $............................................ $............................................... 13. Each partys adjusted share $ $ FORM DC-637 (PAGE ONE OF TWO) 07/04 PDF American LegalNet, Inc. www.USCourtForms.com>>>> 2CHILD SUPPORT GUIDELINES WORKSHEET INSTRUCTIONS General Use monthly financial information rounded to the nearest dollar in making these calculations. To convert data to monthly figures, multiply weekly financial data by 4.33 multiply bi-weekly financial data by 2.167 multiply semi-monthly financial data by 2 divide annual financial data by 12 Amounts of $.50 or more should be rounded up to the nearest llar; amounts less thando $.50 should be rounded down to the nearest dollar. Line 1 Gross income is defined by Virginia Code 20-108.2(C). a. Gross income shall mean all income from all sources, and shall include, but not be limited to, income from salaries, wages, commissions, royalties, bonuses, dividends, severance pay, pensions, interest, trust income, annuities, capital gains, social security benefits, workers compensation benefits, disability insurance benefits, veterans benefits, spousal support, rental income, gifts, prizes or awards. If a parents gross income includes disability insurance benefits, it shall also include any amounts paid to or for the child who is the subject of the order and derived bhe child from the y tparents entitlement to disability insurance benefits. b. Gross income shall not include benefits from public assistance prary Assi stance to Needy Families, auxiliary grants to the aged,lind and disabled, b medical assistance, energy assistance, food stamps, employment services, child care, general ograms as defined in Virginia Code 63.2-100 [Temporary Assieceived, or income received by the payor from secondary employment income not previously included in gross income, where the payor obtained the income to discharge a child support arrearage established by ar administrative order court o and the payor is paying the arrearage pursuant to the order. Line 2 If spousal support is being paid by a party pursuant to an existing court or administrative order or written agreemrdless ent, regaof whether it is being paid to the other party or to a person not a party to this proceeding, subtract that amount under the payees column. If spousal support is being received by a party pursuant to an existing court or administrative order or written agreement,gardl re ess of whether it is being paid by the other party to this proceeding, add the amount under the payees column. Use plus and minus signs appropriately. If a party is not paying orrec eiving spousal support, insert none in the appropriate column(s). Line 3 When a party is paying child support payments pursuant to existing court anor administrative order or written agreement for a child or children who are not the subject of the proceeding, subtract this amount from gross income. When a party has a child or children who are notj