FOLLOWING THESE INSTRUCTIONS NUMBERED TO MATCH THE IDENTIFYING NUMBERS ON THE FORM. TYPE OR PRINT NEATLY USING BLACK INK. The number in brackets after the instructions tells you where to look in the Guidelines for this item, for example, [Guidelines 5].

BASIC INFORMATION

1. Fill in the name, address, and phone number of the person filing the form, and the ATLAS number if it is a title IV-D case. (The spaces marked representing and state bar numbers are used only if an attorney is preparing the form.)

2. Fill in the name of the county in which this worksheet is being filed. (This may already be printed on the form.)

3. If you are providing this information to establish a child support amount, fill in the name, date of birth (DOB), and social security number (SSN) of the person shown as the petitioner on the original petition filed in the case that requests a support order be established. If you are providing this information to modify your current support amount, fill in the name, date of birth (DOB), and social security number (SSN) of the person who is shown as the petitioner on the order that established the current support order.

4. Fill in the name, date of birth (DOB), and social security number (SSN) of the person shown as the respondent on the document you used to answer number 3.

5. Fill in your case number. If you do not have a case number, leave this item blank.

6. Mark the appropriate box or boxes to indicate the party or parties completing the form. NOTE: Terms such as "gross income" and "adjusted gross income" as used here do not have the same meaning as when they are used for tax purposes. "Gross income" is NOT the same as "take-home" pay (gross income is the higher number). If you are converting a weekly "Gross Income" to a monthly amount multiply the weekly amount by 4.33 (52 divided by 12 = 4.33).

7. If you estimate or attribute income in item 8, check the box indicating which parent's income is estimated or attributed, and explain on page 5 of the worksheet the basis for the amount. Examples of ESTIMATED income: He was promoted to supervisor and I know that position pays more; she has the same job as my sister, who works at the same place and makes this amount. Example of ATTRIBUTED income: My ex-wife was a secretary earning $1500/month. Now she has remarried and is staying home as a homemaker.

8. Fill in the total amount of your Gross Income each month. Gross income means the amount before taxes and other deductions are taken out. For income from self-employment, rent, royalties, proprietorship of a business, etc., gross income means gross receipts minus ordinary and necessary expenses, required to produce income. Gross income includes monies from: spousal maintenance (line 9), unemployment benefits, workers compensation, social security, prizes (including lottery winnings), retirement plans, disability benefits (including social security disability), gifts, bonuses, rental income, commissions, severance pay, self-employment, interest, dividends, capital gains, trust income, annuities, and pensions.

Gross income does not include benefits from public assistance programs such as Temporary Assistance for Needy Families (TANF), Food Stamps, General Assistance (GA), and SSI; and, it does not include child support payments you receive.

Also fill in the total monthly Gross income for the other parent, to the best of your knowledge. If a parent is unemployed or underemployed, you may ask the court to attribute income to that parent by entering an estimate of what you think that parent would be earning if he or she worked at full earning capacity. The court shall presume, in the absence of contrary testimony, that a non-custodial parent is capable of full-time employment at least at the federal adult minimum wage. ([Guidelines 4.e.] This presumption does not apply to noncustodial parents under the age of eighteen who are attending high school. If gross income is attributed to the parent receiving support, appropriate child care expenses may also be attributed on line 17.

If you are completing this Parent's Worksheet as part of a modification proceeding and your income is different from the court's most recent findings, you must attach documentation to verify your current income. The documentation should include: your most recent W-2 or 1099 form and your most recent paycheck stub showing year-to-date information. If these are not available, provide other documentation such as a statement of earnings from your employer showing year-to-date income.

If you are completing this Parent's Worksheet as part of a modification proceeding and the income you show for the other party is different from that listed on the court's most recent findings regarding income of the parents, you must attach documentation for it or mark the box in item 7 to show that the income amount is estimated/attributed and, on page 5 of the worksheet form, explain the basis for the amount shown.

ADJUSTMENTS TO MONTHLY GROSS INCOME

9. Fill in the total monthly amount of court-ordered spousal maintenance you and/or the other parent actually pay to a former spouse or receive from a former spouse. Also the amount that is paid or received or will be paid or received in this court case each month. [Guidelines 2.c and 5.a.]

10. Fill in the total amount of court-ordered child support you and/or the other parent actually pay or contribute each month for children from other relationships. [Guidelines 5.a.]

11. You may ask the court to consider the financial obligation you have to support other natural or adopted children for whom there is no court order requiring you to pay support. If you choose to do this, the adjustment amount you may request is determined by a simplified application of the guidelines. [Guidelines 5.b.] On the Schedule of Basic Child Support Obligations, find the amount that is closest to the adjusted gross income amount of the parent requesting an adjustment. Go to the column for the number of children in question. Enter the amount shown there on line 11. Complete item 11 on page 5 of the Worksheet to explain why you are requesting an adjustment, include the names, dates of birth and social security numbers of the children for whom an adjustment is requested.

12. For each parent, add or subtract the numbers on lines 9 through 11 from the number on line 8. Write the result on this line. This is the Adjusted Monthly Gross Income for each parent.

COMBINED ADJUSTED MONTHLY GROSS INCOME

13. Add the two numbers on line 12 together (the one for the Father and the one for the Mother). This total is the Combined Adjusted Monthly Gross Income.

BASIC CHILD SUPPORT OBLIGATION

14. Enter the number of children from this relationship for whom support is being sought in this court action. Complete item 14 on page 5 of the Worksheet, including the names, dates of birth and social security numbers of the children for whom support is requested. Indicate if any of the children are age 12 or older.

15. On the Schedule of Basic Child Support Obligations, locate the amount that is closes to the Combined Adjusted Monthly Gross income listed on line 13. Go to the column for the number of children listed in Item 14. This amount is your Basic Child Support Obligation, enter it on line 15.

ADJUSTMENTS FOR NECESSARY EXPENSES

16. Fill in the monthly dollar amount of that portion of the insurance premium that is or will be paid for court-ordered medical insurance for the children who are the subject of this order. [Guidelines 8.a.] Mark the box to indicate which parent is providing the insurance.

17. If the parent with primary physical custody is working or if you have attributed income to that parent in item 7, fill in the monthly cost of work-related day care that parent pays. [Guidelines 8.b.1.] If these costs vary throughout the year, add the amounts for each month together and divide by 12 to annualize the cost. The court may apportion the benefit the custodial parent derives from any federal child and dependent care tax credits. [Guidelines 8.b.1.]

If the non-custodial parent pays for work-related day care during periods of physical custody, the amount paid by that parent may also be included here (each month's amount added together and divided by 12 to annualize the cost). The annualized amount paid directly by the non-custodial parent may be subtracted under the Non-Custodial Child Care Adjustment section, item 31. Mark the box or boxes to indicate if either or both parents are providing child care. Complete item 17 on page 5.

18. Fill in the monthly amount of reasonable and necessary expenses for special or private schools and special educational activities. These expenses must be agreed upon by both parents or ordered by the court. [Guidelines 8.b.2.]

19. Average expenditures for children age 12 or older are approximately 10% higher than those for younger children. Therefore, if support is being determined for children 12 or older, enter the number of children who are 12 or older and the monthly dollar amount of increase you believe this warrants. The highest possible increase would be 10% of the basic child support obligation. If more than one child is 12 or older divide the basic support obligation by the number of children and multiply that figure by the number of children 12 or older; up to 10% of this amount may be requested as an adjustment. Explain why you think more support is needed on page 5, number 19. [Guidelines 8.b.3.]

20. If any of the children for whom support is being ordered are gifted or handicapped and have special needs that are not recognized elsewhere, the monthly cost of meeting those needs should be entered here. [Guidelines 8.b.4.]

21. Add the amounts from lines 16, 17, 18, 19 and 20. Enter the total amount on this line.

TOTAL CHILD SUPPORT OBLIGATION

22. Add the amounts from lines 15 and 21. Enter the total amount on this line. This is the Total Child Support Obligation amount.

EACH PARENT'S PERCENTAGE (%) OF COMBINED INCOME

Complete the calculations in this section to the best of your knowledge and ability.

23. For each parent, fill in the amount shown on line 12.

24. For each parent, fill in the amount shown on line 13.

25. For each parent, divide the amount written on line 23 by the amount written on line 24. This will probably give you a decimal point answer less than 100%. However, if one parent earns all of the income for the family, this number will be 100%.

     EXAMPLE: Line 23 = $600, Line 24 = $1,000
       $600 / $1,000 = .60 or 60%

EACH PARENT'S PERCENTAGE (%) OF THE TOTAL CHILD SUPPORT OBLIGATION

Complete the calculations in this section to the best of your knowledge and ability.

26. For each parent, fill in the amount shown on line 22.

27. For each parent, fill in the amount shown on line 25.

28. For each parent, multiply the number on line 26 by the number for that parent on line 27. This equals the amount each parent should pay for child support.

     EXAMPLE: Line 26 = $189, Line 27 = 60%
        $189 x .60 = $113.40

ADJUSTMENT FOR COSTS ASSOCIATED WITH VISITATION

29. To adjust for the costs of visitation, first determine the total amount of visitation indicated in a court order or parenting plan or by the expectation or historical practice of the parents. Using the following definitions, add together each period of visitation within twenty-four hours to arrive at the total number of visitation days per year.

A. "One day" means more than 12 continuous and consecutive hours or an overnight.
B. "One-half day" means greater than 4 and up to and including 12 continuous and consecutive hours.
C. "One-quarter day" means up to and including 4 continuous and consecutive hours.

For purposes of calculating visitation days, only the time spent by a child with the noncustodial parent is considered. Time that the child is on school or child care is not considered.

Calculate the total number of visitation days by determining the extended periods of visitation first. Potential midweek visits or weekends should be reduced to reflect time spent on extended visitation periods.

Example: Fathers visitation schedule calls for four weeks of summer visitation alternating weekends and one midweek visit each week. The summer visitation of 4 weeks reduces the potential alternating weekends from 26 to 24. The midweek visits are also reduced from 52 to 48.

After determining the total number of visitation days, refer to the following visitation table. The left two columns of the visitation table set forth numbers of visitation days in increasingly higher ranges. "Reasonable" visitation or visitation consistent with available county visitation/access guidelines will likely fall within the range of days between 73 and 129. Adjacent to each range is an adjustment percentage. The visitation adjustment is calculated as follows: Locate the total number of visitation days per year in the left columns of the visitation table and select the adjustment percentage from the adjacent column. Multiply the basic child support obligation from line 15 by the appropriate adjustment percentage. The number resulting from this multiplication then is subtracted form the proportionate share of the total child support obligation of the parent who exercises visitation.

VISITATION TABLE
NUMBER OF VISITATION DAYS		ADJUSTMENT PERCENTAGE
0	3	0
4	20	.012
21	38	.031
39	57	.050
58	72	.068
73	129	.187
130	148	.255
149	166	.289
167	180	.323

MEDICAL INSURANCE PREMIUM ADJUSTMENT

30. If the parent who will be ordered to make the child support payment is the same parent who will pay the children's medical insurance premium, enter the amount from line 16 here.

NON-CUSTODIAL CHILD CARE ADJUSTMENT

31. If the non-primary custodial parent pays for work related day care during periods of visitation an annualized deduction may be entered here. Complete item 17 on page 5.

COURT APPROVED DISCRETIONARY VISITATION ADJUSTMENT

32. The visitation adjustment section does not consider certain costs usually incurred only by the parent having primary physical custody, such as child's clothing and personal-care items. Upon proof that in the best interests of the child such costs are in fact duplicated or equally shared by the parents or incurred primarily by the noncustodial parent, the court may make a further adjustment if visitation exceeds 129 days per year. The amount of this adjustment is limited to 16 percent of the Basic Child Support Obligation.

PRELIMINARY CHILD SUPPORT AMOUNT

33. For each parent, add the amounts entered on lines 29 through 32. Enter the total on line 33.

34. Deduct the amount on line 33 from line 28.

SELF SUPPORT RESERVE TEST

35. Deduct $645 (the self support reserve) from the adjusted gross income of the parent who will pay support. Enter the resulting amount on line 35. If the resulting amount is less than the preliminary child support amount, the court shall reduce the child support order to the resulting amount. Absent a deviation the preliminary child support amount or the result of the self support reserve test is the amount of the child support to be ordered on line 36.

AMOUNT TO BE ORDERED BASED ON THESE CALCULATIONS

36. The amount on this line is the amount of child support that should be ordered based on your calculations. ENTER THE LESSER AMOUNT FROM LINE 34 OR 35.

DEVIATION FROM THE GUIDELINES AMOUNT

37. The court shall deviate form the guidelines, i.e., order support in an amount different from the amount which is calculated under these guidelines, if an order would be unjust or inappropriate. Show the total support amount you believe should be ordered. A deviation can only be ordered if the court makes appropriate findings. Complete item 37 on page 6 if you believe a deviation is warranted. [Guidelines 17]

RESPONSIBILITY FOR VISITATION-RELATED TRAVEL EXPENSES

38. The court may allocate the costs of visitation-related travel. On page 6, item 38, describe the expected visitation plan and related travel/transportation expenses. On this line, list the dollar amount or percentage you think each parent should pay toward the travel/transportation costs. The court will decide how to allocate the expense. The allocation of expense does not change the amount of the support ordered on line 36. [Guidelines 15]

RESPONSIBILITY FOR MEDICAL EXPENSES NOT PAID BY INSURANCE

39. The court must specify each parent's proportionate share of uninsured medical expenses for the children. Based on each parent's ability to pay, indicate what you think this percentage should be for each parent. The court will make the final decision. [Guidelines 8.a.]

SIGNATURE LINE

40. The person completing the worksheet must sign here before a Notary Public or Court Clerk affirming the correctness of the information. (If both parents complete the form together, both should sign here.)

WHEN YOU HAVE COMPLETED THIS WORKSHEET:

If you are completing this worksheet to establish a child support obligation: