Form 3.0 Child Support Computation Worksheet CHILD SUPPORT

Form 3.0 Child Support Computation Worksheet
CHILD SUPPORT COMPUTATION WORKSHEET SOLE RESIDENTIAL PARENT
OR SHARED PARENTING ORDER
Name of Parties: __________________________________________________________________________
Case No: ____________________________________
Number of Minor Children: _____________________
The following parent was designated as residential parent and legal custodian:
☐ Mother
☐ Father
☐ Shared
Column I
FATHER
Column II
MOTHER
Column III
COMBINED
___________
___________
____________
(Include in Column I and/or Column II the average of
the three years or the Year 1 amount, whichever is
less, if there exists a reasonable expectation that the
total earnings from overtime and/or bonuses during
the current calendar year will meet or exceed the
amount that is the lower of the average of the three
years or the Year 1 amount. If, however, there exists
a reasonable expectation that the total earnings
from overtime/bonuses during the current calendar
year will be less that the lower of the average of the
three years or the Year 1 amount, include only the
amount reasonably expected to be earned this
year.)........................................................................... ___________
___________
____________
INCOME:
1a Annual gross income from employment or, when
determined appropriate by the Court or Agency,
average annual gross income from employment
over a reasonable period of years. (Exclude
overtime, bonuses, self employment income, or
commissions) ............................................................
1b
2
a
b
c
d
Amount of overtime, bonuses, and commissions
(Year 1 representing the most recent year)
Father
Mother
Year 3 (3 years ago)
_________
_________
Year 2 (2 years ago)
_________
_________
Year 1 (Last year)
_________
_________
Average:
_________
_________
For self-employed income:
Gross receipts from business.....................................
Ordinary and necessary business expenses...............
5.6% of adjusted gross income or the actual
marginal difference between the actual rate paid by
the self-employed individual and the F.I.C.A. rate....
Adjusted gross income from self-employment
(subtract the sum of 2b and 2c from 2a)...................
___________
___________
___________ ____________
___________ ____________
___________
___________
____________
___________
___________
____________
Name of Parties: __________________________________ Case No:_____________________________
SOLE RESIDENTIAL PARENT OR SHARED PARENTING WORKSHEET - PAGE 2
Column I
FATHER
Column II
MOTHER
Column III
COMBINED
Annual income from interest and dividends (whether
or not taxable)............................................................
___________
___________
____________
4
Annual income from unemployment compensation .
___________
___________
____________
5
Annual income from workers’ compensation,
disability insurance benefits, or social security
disability/retirement benefits.....................................
___________
___________
____________
___________
___________
____________
3
6
Other annual income (identify)..................................
__________________________________________
7a
Total annual gross income (add lines 1a, 1b, 2d, and
3 - 6)..........................................................................
___________
___________
____________
Health insurance maximum (multiply line 7a by 5%)
___________
___________
____________
Adjustment for minor children born to or adopted by
either parent and another parent who are living with
this parent; adjustment does not apply to stepchildren (number of children times federal income
tax exemption less child support received, not to
exceed the federal tax exemption).............................
___________
___________
____________
9
Annual court-ordered support paid for other children
___________
___________
____________
10
Annual court-ordered spousal support paid to any
spouse or former spouse............................................
___________
___________
____________
Amount of local income taxes actually paid or
estimated to be paid...................................................
___________
___________
____________
Mandatory work-related deductions such as union
dues, uniform fees, etc. (Not including taxes, social
security, or retirement)..............................................
___________
___________
____________
Total gross income adjustments (add lines 8 through
12)..............................................................................
___________
___________
____________
14a Adjusted annual gross income (subtract line 13 from
line 7a)........................................................................
___________
___________
____________
7b
ADJUSTMENTS TO INCOME
8
11
12
13
Form 3.0 Child Support Computation Worksheet
Name of Parties: ____________________________________ Case No: _____________________________
SOLE RESIDENTIAL PARENT OR SHARED PARENTING WORKSHEET - PAGE 3
Column I
FATHER
14b Cash medical support maximum (If amount on line 7a,
Col I, is under 150% of federal poverty level for an
individual, enter $0 on line 14b, Col I. If amount on
line 7a, Col I, is 150% or higher of federal poverty
level for an individual, multiply amount on line 14a,
Col I, by 5% and enter this amount on line 14b, Col I.
If amount on line 7a, Col II, is under 150% of federal
poverty level for an individual, enter $0 on line 14b,
Col II. If amount on line 71, Col II, is 150% or higher
of federal poverty level for an individual, multiply
amount on line 14a, Col II, by 5% and enter this
amount on line 14b, Col II.)......................................
___________
15
___________
Column III
COMBINED
____________
Combined annual income that is basis for child
support order (add line 14a, Col I and Col II)...........
16
a
Percentage of parent’s income to total income
Father (divide line 14a, Col II, by line 15, Col III)....
b
Mother (divide line 14a, Col II, by line 15, Col III)..
17
Basic combined child support obligation (refer to
schedule, first column, locate the amount nearest to
amount on line 15, Col III, then refer to column
for number of children in this family. If the
income of the parties is more than one sum but
less than another, you may calculate difference).......
(See enclosed schedule or O.R.C. 3119.021)
18
a
Annual support obligation per parent
Father (multiply line 17, Col III, by line 16a)............
b
Mother (multiply line 17, Col III, by line 16b).........
19
Annual child care expenses for children who are the
subject of this order that are work, employment,
training or education related, as approved by the
court or agency (deduct tax credit from annual cost,
whether or not claimed)
Father.........................................................................
a
Column II
MOTHER
b Mother.......................................................................
____________
___________%
___________%
____________
___________
___________
___________
___________
Name of Parties: ___________________________________
Case No: _____________________________
SOLE RESIDENTIAL PARENT OR SHARED PARENTING WORKSHEET - PAGE 4
Column I
FATHER
20a Marginal, out-of-pocket costs, necessary to provide
for health insurance for children who are subject of
this order (contributing cost of private family health
insurance, minus contributing cost of private single
health insurance, divided by the total number of
dependents covered by plan, including children subject
of the support order, times number of children subject
of the support order)..................................................
___________
20b Cash medical support obligation (enter amount on
line 14b or amount of annual health care expenditures
estimated by US Dept of Agriculture and described
in O.R.C. 3119.30, whichever amount is lower)......
___________
ADJUSTMENTS TO CHILD SUPPORT WHEN
HEALTH INSURANCE IS PROVIDED:
a Father (only if obligor or shared parenting)
Additions: line 16a times sum of amounts shown on
line 19, Col II and line 201, Col I..............................
b Mother (only if obligor or shared parenting)
Additions: line 16b times sum of amounts shown on
line 19, Col I and line 201, Col I...............................
c Father (only if obligor or shared parenting)
Subtractions: line 16b times sum of amounts shown
on line 19, Col I and line 201, Col I........................
d Mother (only if obligor or shared parenting)
Subtractions: line 16a times sum of amounts shown
on line 19, Col II and line 20a, Col II........................
Column II
MOTHER
___________
____________
___________
____________
21
22
a
b
___________
___________
___________
OBLIGATION AFTER ADJUSTMENTS TO CHILD
SUPPORT WHEN HEALTH INSURANCE IS
PROVIDED
Father: Line 18a plus or minus the difference
between line 21a minus line 21c...............................
___________
Mother: Line 18b plus or minus the difference
between line 21b minus line 21d...............................
ACTUAL ANNUAL OBLIGATION WHEN HEALTH
INSURANCE IS PROVIDED
a (Line 22a or line 22b, whichever line corresponds to
the parent who is the obligor)....................................
___________
b Any non-means-tested benefits, including social
security and veterans’ benefits, paid to and received
by a child or a person on behalf of the child due to
death, disability, or retirement of the parent..............
___________
Column III
COMBINED
___________
___________
23
___________
___________
Form 3.0 Child Support Computation Worksheet
Name of Parties: ____________________________________
Case No. ___________________________
SOLE RESIDENTIAL PARENT OR SHARED PARENTING WORKSHEET - PAGE 5
c Actual annual obligation (subtract line 23b from
line 23a).....................................................................
ADJUSTMENTS TO CHILD SUPPORT WHEN
INSURANCE IS NOT PROVIDED:
a Father (only if obligor or shared parenting)
Additions: line 16a times the sum of the amounts
shown on line 19, Col II and line 20b, Col II............
b Mother (only if obligor or shared parenting)
Additions: line 16b times sum of amounts shown on
line 19, Col I and line 20b, Col I...............................
c Father (only if obligor or shared parenting)
Subtractions: line 16b times sum of amounts shown
on line 19, Col I and line 20b, Col I..........................
d Mother (only if obligor or shared parenting)
Subtractions: line 16a times sum of amounts shown
on line 19, Col II and line 20b, Col II........................
Column I
FATHER
Column II
MOTHER
___________
___________
24
25
a
b
26
a
b
c
___________
___________
___________
OBLIGATION AFTER ADJUSTMENTS TO CHILD
SUPPORT WHEN HEALTH INSURANCE IS NOT
PROVIDED
Father
Line 18a plus or minus the difference between line
24a minus line 24c.....................................................
___________
Mother
Line 18b plus or minus the difference between line
24b minus line 24d....................................................
___________
___________
ACTUAL ANNUAL OBLIGATION WHEN HEALTH
INSURANCE IS NOT PROVIDED
(Line 25a or line 25b, whichever line corresponds to
the parent who is the obligor)....................................
____________ ___________
Any non-means-tested benefits, including social
security and veterans’ benefits, paid to and received
by a child or a person on behalf of the child due to
death, disability, or retirement of the parent..............
___________ ___________
Actual annual obligation (subtract line 26b from
line 26a).....................................................................
___________
___________
27a Deviation from sole residential parent support
amount shown on line 23c if amount would be unjust
or inappropriate: (See O.R.C. 3119.23) (Specific facts
And monetary value must be stated.)........................
___________
__________________________________________
___________
Column III
COMBINED
Name of Parties: ___________________________________
Case No: _____________________________
SOLE RESIDENTIAL PARENT OR SHARED PARENTING WORKSHEET - PAGE 6
Column I
FATHER
b
Column II
MOTHER
Column III
COMBINED
Deviation from shared parenting order: (See O.R.C.
3119.23 and 3119.24). (Specific facts including
amount of time children spend with each parent,
ability of each parent to maintain adequate housing
for children, and each parent’s expenses for children
MUST be stated to justify deviation.
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Adjustment (+/-) of Father........................................
Adjustment (+/-) of Mother......................................
28
29
30
31
___________
___________
FINAL CHILD SUPPORT FIGURE (Amount WHEN HEALTH WHEN HEALTH
reflects final annual child support obligation; in
INSURANCE IS
INSURANCE IS
Col I, enter line 23c plus or minus any amounts
PROVIDED:
NOT PROVIDED:
indicated in line 27a or 27b; in Col II, enter line
26c plus or minus any amounts indicated in line
27a or 27b)................................................................
___________ ___________
FOR DECREE
Child support per month (divide obligor’s annual
share, line 28, by 12) plus 2% processing fee...........
___________
___________
FINAL CASH MEDICAL SUPPORT FIGURE:
(This amount reflects the final, annual cash medical
support to be paid by the obligor when neither
parent provides health insurance coverage for the
child; enter obligor’s cash medical support amount
from line 20b)............................................................
___________
FOR DECREE: Cash medical support per month
(divide line 30 by 12)................................................
___________
Prepared by: ________________________________________________________
Counsel (For ☐ Mother; or ☐ Father) or Pro Se or Other
Worksheet has been reviewed and agreed to:
_____________________________________________
Father
Date: ___________________________________
_____________________________________________
Mother
Date: __________________________________
Obligor:
☐Father
☐Mother