1. AGE, NUMBER, AND PARENTING OF CHILDREN
a. Number of children who may be eligible to be covered by this order?
b. Check the option that applies to the children listed in 1(a) (check one box only)
The parents share financial responsibilities and parenting time approximately equally (shared)
Box 1
The children primarily reside with one parent for approximately 2/3 of the time
Box 2
There is more than one child covered by the order and each parent provides a primary residence for at least one child (split)
Box 3
c. Enter Each Parent's name
If you checked Box 2 above, enter the name of the parent with whom the children primarily reside in the column for Parent A, and the other parent's name as Parent B; otherwise, enter either parent's name in either column
Parent A:
Parent B:
Enter the number and age of children for whom each parent may be eligible to receive support
If you checked Box 1 above (shared), enter the number of children from 1(a) in the columns for both parents
If you checked Box 2 above, enter the number of children from 1(a) in the column for Parent A, and enter 0 in the column for Parent B
If you checked Box 3 above (split), enter the number of children primarily residing with each parent in each column
d. Number of children under age 18
e. Number of children 18 years or older
f. Total Number of children
Total number of children should be equal to 1(a) i.e. {{child_count}}
2. Income
a. Gross weekly income
Parent A
Parent B
b. Minus Child care cost paid
Parent A
Parent B
c. Minus Health care cost paid
Parent A
Parent B
d. Minus Dental/vision insurance cost paid
Parent A
Parent B
e. Minus Other support obligations paid
Parent A
Parent B
Case Name:
Docket Number:
Date Prepared:
Name of Preparer:
Payor's final support obligation
f. Available Income
Parent A
Parent B
g. Combined Available Income
h. Share of Combined Available Income
Parent A
Parent B
3. Gross Support Amounts
a. Applicable available income
b. Support amount for one child
c. Adjustment for the number of children in 1(f)
Parent A
Parent B
d. Combined support amount
Parent A
Parent B
4. Adjustment for children 18 years or older
a. Adjustment percentage for the ages of the children listed in 1(d) and 1(e)
Parent A
Parent B
b. Adjustment for childrend 18 yeas or older
Parent A
Parent B
c. Adjusted combined support amount
Parent A
Parent B
5. Proportional Support Amounts
a. Minus each parent's share of support
Parent A
Parent B
b. Other parent's share of support
Parent A
Parent B
c. Support as % of each parent's available income
Parent A
Parent B
d. Other parent's adjusted share of support
Parent A
Parent B
e. Recipient and Payor
Parent A
Parent B
f. Payor's net share of support
6. adjustment for child care and health care costs
a. Child care and health care cost paid
Parent A
Parent B
b. Payor's share of Recipient's cost
c. Minus Recipient's share of Payor's cost
d. Payor's net cost
e. Maximum adjustment amount
f. Adjustment applied to this order
g. Adjustment applied to this order
h. Payor's adjusted net share of support
7. PAYOR'S NET SUPPORT OBLIGATION
a. Support as % of Recipient's available income
b. Payor's final support obligation
8. ADDITIONAL INCOME ABOVE $4808
a. Combined additional income
b. Payor's final support obligation
Parent A:
Parent B: