Court Form 1A
Rev. 7/1/01
Worksheet
Huron County Domestic Relations Court
Child Support Computation
Sole Residential Parent or Shared Parenting Order
Name of parties ___________________________________________________ Case No._________________________
_____________________________________________________ JUDGE EARL R. McGIMPSEY
The following parent was designated as the residential parent and legal custodian: _______ mother ________ father
________ shared Number of minor children _______
Father has _________ pay periods annually; mother has __________ pay periods annually.
Column I Column II Column III
INCOME Father Mother Combined
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).
b. Amount of overtime, bonuses, and commissions
Father Mother
Yr. 3 (three years ago) $_________ $_________
Yr. 2 (two years ago) $_________ $_________
Yr. 1 (last calendar year) $_________ $_________
Average: $_______ $_________
(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 than 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)
$_________ $__________
2. For self-employment income:
a. Gross receipts from business $_________ $__________
b. Ordinary and necessary business expenses $_________ $_________
c. 5.6% of adjusted gross income or the actual marginal difference
between the actual rate paid by the self-employed individual and
the FICA rate. $_________ $__________
d. Adjusted gross income from self-employment (subtract the sum of 2b and 2c from 2a) $_________ $__________
3. Annual income from interest and dividends (whether or not taxable) $_________ $__________
4. Annual income from unemployment compensation $_________ $ _________
5. Annual income from worker’s compensation, disability insurance benefits,
or social security disability/retirement benefits. $_________ $__________
6. Other annual income (identify)_______________________________________ $_________ $__________
7. Total annual gross income (add lines 1a, 1b, 2d and 3-6) $_________ $__________
ADJUSTMENTS TO INCOME
8. 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 $________ $________
11. Amount of local income taxes actually paid or estimated to be paid $________ $________
12. Mandatory work-related deductions such as union dues, uniform fees, etc.
(Not including taxes, social security, or retirement) $________ $________
13. Total gross income adjustments (add lines 8-12) $________ $________
14. Adjusted annual gross income (subtract line 13 from line 7) $________ $________
15. Combined annual income that is basis for child support order
(add line 14, Col. I & Col. II) $________ $________
16. Percentage parent’s income to total income
a. Father (divide line 14, Col. I by line 15, Col. III) _________%
b. Mother (divide line 14, Col. II by line 15, Col. III) __________+_______% = 100%
17. Basic combined child support obligation (refer to basic child support schedule in division (D) of section 3119.021 of the Revised Code; in the first column of the schedule, locate the sum that is nearest to the combined annual income listed in line 15, Col. III of this worksheet, then refer to the column of the schedule that corresponds to the number of children in this family. If the income of the parents is more than one sum, and less than another sum, in the first column of the schedule, you may calculate the basic combined child support obligation based upon the obligation for those two sums.) $___________
18. Annual support obligation/parent
a. 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 the children who are subject of this order that are work,
employment training, or education related as approved by the Court or agency
(deduct the tax credit from annual cost whether or not claimed) $_______ $_________
*State day-care tax credits included if applicable: Yes No
20. Marginal, out-of-pocket costs, necessary to provide for health insurance
for the children who are subject of this order. $________ $_________
21. ADJUSTMENTS TO CHILD SUPPORT
Father or Mother (only if obligor or shared parenting)
a. FATHER ADDITIONS: Line 16a times sum of amounts shown on line 19, Col. II $____________
and line 20, Col. II.
b. MOTHER ADDITIONS: Line 16b times sum of amounts shown on line 19, Col. I $_____________
and line 20, Col. I.
c. FATHER SUBTRACTIONS: Line 16b times sum of amounts shown on line 19, Col I
and line 20, Col. I. $________
d. MOTHER SUBTRACTIONS: Line 16a times sum of amounts shown on line 19, Col. I
and line 20, Col. II. $_________
22. OBLIGATION AFTER ADJUSTMENTS TO CHILD SUPPORT
a. FATHER: Line 18a plus 21a minus line 21c (if the amount on
line 21c is greater than or equal to the amount on line 21a or
if 21a and 21c are not applicable - enter the number on
line 18a in Col. I) $________
b. MOTHER: Line 18b plus line 21b minus line 21d (if the amount on
21d is greater than or equal to the amount on line 21b or if
21b and 21d are not applicable - enter the number on line 18b in Col. II) $________
23. ACTUAL ANNUAL OBLIGATION
a. (Line 22a or, 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. $_________
c. Actual annual obligation (subtract line 23b from line 23a) $__________
24. a. Deviation from sole residential parent support amount shown on line 23c if amount
would be unjust or inappropriate: (see section 3119.23 of the Revised Cod.)(Specific
facts and monetary value must be stated.) $_________
b. Deviation from shared parenting order: (see sections 3119.23 and 3119.24 of
the Revised Code.) (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.) $_________
Stated below are specific facts to justify deviation
25. FINAL FIGURE (this amount reflects final annual child support obligation:
Line 23c plus or minus any amounts indicated in line 24a or 24b) $__________
26. FOR DECREE: Child support per month (divide obligor’s annual share,
Line 25, by 12) $__________
plus any processing charge. _______
OBLIGOR: FATHER/MOTHER $__________
(forms/Court Form 1A)
Calculations have been reviewed:
Signatures:
_______________________________________________ I do/do not consent.
Father
Sworn to before me and subscribed in my presence, this _______ day of ____________________, _______.
________________________________________
Notary Public
My expiration is
______________________________________________ I do/do not consent.
Mother
Sworn to before me and subscribed in my presence, this ______ day of ______________________. _______.
________________________________________
Notary Public
My expiration is
_____________________________________ _____________________________________
Attorney for Father Attorney for Mother
(forms/Court Form 1A)