A.   The order [  ] does [  ] does not replace a prior court or administrative order.

B.   The Standard Calculation listed on line 17 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)

[  ] Child(ren) 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.

Income was imputed for the following reasons:________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________.

F.   If applicable:  [  ] All health care, day care and special child rearing expenses are included in the worksheets in Part III.

Child(ren) and Age(s): 

Part I:  Income  (see Instructions, page 6)

1.  Gross Monthly Income

Father

Mother

            a.         Wages and Salaries

$

$

            b.         Interest and Dividend Income

$

$

            c.         Business Income

$

$

            d.         Maintenance Received

$

$

            e.         Other Income

$

$

            f.          Imputed Income

$

$

            g.         Total Gross Monthly Income (add lines 1a through 1f)

$

$

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.         Mandatory Pension Plan Payments

$

$

            f.          Voluntary Retirement Contributions

$

$

            g.         Maintenance Paid

$

$

            h.         Normal Business Expenses

$

$

            i.          Total Deductions from Gross Income

                        (add lines 2a through 2h)

$

$

3.  Monthly Net Income  (line 1g minus 2i)

$

$

4.  Combined Monthly Net Income

            (add father’s and mother’s monthly net incomes from line 3)

$

5.  Basic Child Support Obligation  (enter total amount in box ®)

Child #1 _________ Child #3 __________ Child #5 __________

Child #2 _________ Child #4 __________

$

6.  Proportional Share of Income

            (each parent’s net income from line 3 divided by line 4)

                        .

                        .

Part II:  Basic Child Support Obligation  (see Instructions, page 7)

7.  Each Parent’s Basic Child Support Obligation without consideration of low income limitations. (Multiply each number on line 6 by line 5.)

$

$

8.  Calculating low income limitations:  Fill in only those that apply.

Self-Support Reserve:  (125% of the Federal Poverty Guideline.)

$

a. Is combined Net Income Less Than $1,000?  If yes, for each parent, enter the presumptive $50 per child.

$

$

b. Is Monthly Net Income Less Than Self-Support Reserve? If yes, for that parent enter the presumptive $50 per child.

$

$

c. Is Monthly Net Income Greater Than Self-Support Reserve? If yes, for each parent subtract the self-support reserve from line 3. If that amount is less than line 7, then enter that amount or the presumptive $50 per child, whichever is greater.

$

$

9.  Each parent’s basic child support obligation after calculating applicable limitations.  For each parent, enter the lowest amount from line 7, 8a - 8c, but not less than the presumptive $50 per child.

$

$

Part III:  Health Care, Day Care, and Special Child Rearing Expenses  (see Instructions, page 8)

10.  Health Care Expenses

Father

Mother

            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 10a plus line 10b)

$

$

            d.         Combined Monthly Health Care Expenses

                        (add father’s and mother’s totals from line 10c)

$

11.  Day Care and Special 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 11a through 11d)

$

$

12.  Combined Monthly Total Day Care and Special Expenses (add father’s and mother’s day care and special expenses from line 11e)

$

13.  Total Health Care, Day Care, and Special Expenses (line 10d plus line 12)

$

14.  Each Parent’s Obligation for Health Care, Day Care, and Special Expenses (multiply each number on line 6 by line 13)

$

$

Part IV: Gross Child Support Obligation

15.  Gross Child Support Obligation (line 9 plus line 14)

$

$

Part V:  Child Support Credits  (see Instructions, page 9)

16.  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 16a through 16c)

$

$

Part VI:  Standard Calculation/Presumptive Transfer Payment  (see Instructions, page 9)

17.  Standard Calculation (line 15 minus line 16d or $50 per child whichever is greater)

$

$

Part VII:  Additional Informational Calculations

18.  45 % of each parent’s net income from line 3 (.45 x amount from line 3 for each parent)

$

$

19.  25% of each parent’s basic support obligation from line 9  (.25 x amount from line 9 for each parent)

$

$

Part VIII:  Additional Factors for Consideration  (see Instructions, page 9)

20.  Household Assets

      (List the estimated present value of all major household assets.)

Father’s

Household

Mother’s

Household

            a.         Real Estate

$

$

            b.         Investments

$

$

            c.         Vehicles and Boats

$

$

            d.         Bank Accounts and Cash

$

$

            e.         Retirement Accounts

$

$

            f.          Other (describe)

$

$

$

$

21.  Household Debt

(List liens against household assets, extraordinary debt.)

$

$

$

$

$

$

22.  Other Household Income

     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. Gross income from overtime or from second jobs the party is asking the court to exclude per Instructions, page 10

       _________________________________________________

$

$

    d. Income Of Child(ren) (if considered extraordinary)

       Name __________________________________________

       Name __________________________________________

$

$

$

$

    e. Income From Child Support

       Name __________________________________________

       Name __________________________________________

$

$

$

$

    f. Income From Assistance Programs

       Program ________________________________________

       Program ________________________________________

$

$

$

$

    g. Other Income (describe)

       ________________________________________________

       ________________________________________________

$

$

$

$

23.  Non-Recurring Income (describe)

       _________________________________________________

       _________________________________________________

$

$

$

$

24.  Child Support Owed, Monthly, for Biological or Legal Child(ren)

Father’s

Household

Mother’s

Household

Name/age: _____________________________ Paid  [ ] Yes  [ ] No

$

$

Name/age: _____________________________ Paid  [ ] Yes  [ ] No

$

$

Name/age: _____________________________ Paid  [ ] Yes  [ ] No

$

$

25.  Other Child(ren) Living In Each Household

      (First name(s) and age(s))

26.  Other Factors For Consideration (attach additional pages as necessary)

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                                                  Father’s Signature

Date                                      City                           Date                                           City