Washington State Child Support Schedule Worksheets [ ] Proposed by [ ] Mother [ ] Father [ ] State of WA [ ] Other ________________. (CSWP) Or, [ ] Signed by the Judicial/Reviewing Officer. (CSW) Mother _____________________________ Father _______________________________ County ____________________ Superior Court/OAH Case No. ____________________ Child Support Order Summary Report A. The order [ ] does [ ] does not replace a prior court or administrative order. B. The Standard Calculation listed on line 15e of the Worksheet for the paying parent is: $___________________. C. The Transfer Amount ordered by the Court from the Order of Child Support is: $____________________ to be paid by [ ] mother [ ] father. D. The Court deviated (changed) from the Standard Calculation for the following reasons: [ ] Does not apply [ ] Nonrecurring income [ ] Sources of income and tax planning [ ] Split custody [ ] Residential schedule (including shared custody) [ ] Children from other relationships for whom the parent owes support [ ] High debt not voluntarily incurred and high expenses for the child(ren) [ ] Other (please describe): _______________________________________________________ ___________________________________________________________________________. E. Income for the Father is [ ] imputed [ ] actual income. Income for the Mother is [ ] imputed [ ] actual income. F. If applicable: [ ] All health care, day care and special child rearing expenses are included in the worksheets in Part II. Worksheets Children and Ages: Part I: Basic Child Support Obligation (See Instructions, Page 1) 1. Gross Monthly Income a. Wages and Salaries b. Interest and Dividend Income c. Business Income d. Maintenance Received e. Other Income f. Total Gross Monthly Income (add lines 1a through 1e) Father Mother $ $ $ $ $ $ $ $ $ $ $ $ WSCSS-Worksheets – Mandatory (CSW/CSWP) 6/2008 Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com 2. Monthly Deductions from Gross Income a. Income Taxes (Federal and State) b. FICA (Soc.Sec.+Medicare)/Self-Employment Taxes c. State Industrial Insurance Deductions d. Mandatory Union/Professional Dues e. Pension Plan Payments f. Maintenance Paid g. Normal Business Expenses h. Total Deductions from Gross Income (add lines 2a through 2g) 3. Monthly Net Income (line 1f minus 2h) 4. Combined Monthly Net Income Father Mother $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ (add father’s and mother’s monthly net incomes from line 3) (If combined monthly net income is less than $600, skip to line 7.) $ 5. Basic Child Support Obligation (enter total amount in box →) Child #1 ________________ Child #3 _________________ Child #2 ________________ Child #4 _________________ 6. Proportional Share of Income (each parent’s net income from line 3 divided by line 4) 7. Each Parent’s Basic Child Support Obligation (multiply each number on line 6 by line 5) (If combined net monthly income on line 4 is less than $600, enter each parent’s support obligation of $25 per child. Number of children: ________. Skip to line 15a and enter this amount.) $ . . $ $ Part II: Health Care, Day Care, and Special Child Rearing Expenses (See Instructions, Page 3) 8. Health Care Expenses a. Monthly Health Insurance Premiums Paid for Child(ren) $ $ b. Uninsured Monthly Health Care Expenses Paid for Child(ren) c. Total Monthly Health Care Expenses (line 8a plus line 8b) d. Combined Monthly Health Care Expenses (add father’s and mother’s totals from line 8c) e. Maximum Ordinary Monthly Health Care (multiply line 5 times .05) f. Extraordinary Monthly Health Care Expenses (line 8d minus line 8e., if “0” or negative, enter “0”) 9. Day Care and Special Child Rearing Expenses a. Day Care Expenses b. Education Expenses c. Long Distance Transportation Expenses d. Other Special Expenses (describe) $ $ $ $ $ $ $ $ $ $ $ $ $ e. Total Day Care and Special Expenses (add lines 9a through 9d) $ $ $ $ $ $ $ $ 10. Combined Monthly Total Day Care and Special Expenses (add father’s and mother’s day care and special expenses from line 9e) $ WSCSS-Worksheets – Mandatory (CSW/CSWP) 6/2008 Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 11. Total Extraordinary Health Care, Day Care, and Special Expenses (line 8f plus line 10) $ Father 12. Each Parent’s Obligation for Extraordinary Health Care, Day Care, and Special Expenses (multiply each number on line 6 by Mother Part III: Gross Child Support Obligation 13. Gross Child Support Obligation (line 7 plus line 12) Part IV: Child Support Credits (See Instructions, Page 3) 14. Child Support Credits a. Monthly Health Care Expenses Credit b. Day Care and Special Expenses Credit c. Other Ordinary Expenses Credit (describe) d. Total Support Credits (add lines 14a through 14c) $ $ $ $ $ $ $ $ $ line 11) $ $ $ Part V: Standard Calculation/Presumptive Transfer Payment (See Instructions, Page 4) 15. Standard Calculation $ $ a. Amount from line 7 if line 4 is below $600. Skip to Part VI. b. Line 13 minus line 14d, if line 4 is over $600 (see below if appl.) $ $ Limitation standards adjustments c. Amount on line 15b adjusted to meet 45% net income limitation $ $ d. Amount on line 15b adjusted to meet need standard limitation $ $ e. Enter the lowest amount of lines 15b, 15c or 15d $ $ Part VI: Additional Factors for Consideration (See Instructions, Page 4) 16. Household Assets Father’s (List the estimated present value of all major household Household assets.) a. Real Estate $ b. Stocks and Bonds $ c. Vehicles $ d. Boats $ e. Pensions/IRAs/Bank Accounts $ f. Cash $ g. Insurance Plans $ h. Other (describe) $ $ $ 17. Household Debt (List liens against household assets, extraordinary debt.) $ $ $ Mother’s Household $ $ $ $ $ $ $ $ $ $ $ $ $ WSCSS-Worksheets – Mandatory (CSW/CSWP) 6/2008 Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com Father’s Household (Household Debt continued) Mother’s Household $ $ $ $ $ $ a. Income Of Current Spouse or Domestic Partner (if not the other parent of this action) Name __________________________________________ $ $ Name __________________________________________ $ $ b. Income Of Other Adults In Household Name __________________________________________ $ $ Name __________________________________________ $ $ c. Income Of Children (if considered extraordinary) Name __________________________________________ $ $ Name __________________________________________ $ $ d. Income From Child Support Name __________________________________________ $ $ Name __________________________________________ $ $ e. Income From Assistance Programs Program ________________________________________ $ $ Program ________________________________________ $ $ f. Other Income (describe) ________________________________________________ $ $ ________________________________________________ $ $ 19. Non-Recurring Income (describe) _________________________________________________ $ $ _________________________________________________ $ $ Name/age: _________________________________________ $ $ Name/age: _________________________________________ $ $ Name/age: _________________________________________ 21. Other Children Living In Each Household $ $ 18. Other Household Income 20. Child Support Paid For Other Children (First names and ages) WSCSS-Worksheets – Mandatory (CSW/CSWP) 6/2008 Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com 22. Other Factors For Consideration Signature and Dates I declare, under penalty of perjury under the laws of the State of Washington, the information contained in these Worksheets is complete, true, and correct. Mother’s Signature Date Father’s Signature City _______________________________________ Judge/Reviewing Officer Date City _______________________________________ Date This worksheet has been certified by the State of Washington Administrative Office of the Courts. Photocopying of the worksheet is permitted. WSCSS-Worksheets – Mandatory (CSW/CSWP) 6/2008 Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com