Petitioner: Respondent: Date:    
  Weekly Biweekly Monthly Annually Income Weekly Biweekly Monthly Annually   File No: Petition No: DCSS No:    
  Wages              
  2d Job   NET INCOME AVAILABLE 1 Gross Income   Wages 2d Job Other Self      
  other   1      
  Self employment        
  Pay Period       Pay Period       2 Self-Employment Adjustment (7% of Documented Self-Employment Income to the      
  Start End Total Year-To-Date Start End Total   extent wages and self-employment income do not exceed ) 2  
  Month Weekly or Month   3 Deductions Pension Union Dues Disability other        
  Day Monthly Bi-weekly Day Monthly   3    
  Year   Year      
  Weekly Biweekly Monthly Annually Deductions Weekly Biweekly Monthly Annually   4 Health Insurance HI on childx50 or 75% = Net HI on child + HI not on child      
  Pension $   If Line 7A = No, 50%   4      
    x Wages Pension %   x Wages   If Line 7A = Yes, 75%        
  Union Dues   5 Self Support Allowance 5    
  Disability   6 Net Income after Self Support (Line 1 minus Lines 2, 3, 4 and 5) 6    
  other   7 A - Does the parent support other dependent children? (Yes or No) 7A    
          Health Insurance
(covering these children)		           B - Adjustment for Other Dependents (If Line 7A=Yes, then 70%; otherwise 100%) B Total    
  Weekly Biweekly Monthly Annually Weekly Biweekly Monthly Annually   8 Net Income Available for Primary Support (Line 6 x Line 7B) 8    
  MajorMedical   PRIMARY 9 Share of Net Available (Line 8 / Line 8 Total; 50% nonparent override: ) 9 100%    
  Dental   10 Number of children of this union in each home 10    
  Vision   11 Primary Support Allowance (Line 10 x + ) 11    
  Step-parent/Guardian   12 Itemized Primary Childcare Tuition other Health Ins*        
          Health Insurance
(NOT on these children)		           *Premium not 12      
  Weekly Biweekly Monthly Annually Weekly Biweekly Monthly Annually   included on Line 4   Total    
  MajorMedical   13 Total Primary Need (Line 11 + Lines 12A, B and C) 13    
  Dental   14 Primary Support Obligation (Line 8 x Line Line 13 Total) 14    
  Vision   SOLA Standard of Living Adjustment 15 - Net Income Available for SOLA   15 Total  
  Weekly Biweekly Monthly Annually Itemized Primary Weekly Biweekly Monthly Annually   # children SOLA % 16A - Line 15 - $15,000 but not less than "0" 16A  
  Childcare   1 B - High Income Offset (20% of Line 16A Total) B  
  Tuition   2 17 - Standard of Living Percentage (Table) 17 Total    
  Other   3 18A - SOLA (Line 15 - Line 16B x Line 17) 18A    
                        each add'l B - Per child SOLA (Line 18A Total / Line 10 Total) B        
    Y or N     Other Children     Y or N     CREDITS 19 Gross Obligation (Line 14 + Line18A) 19      
   
Does the parent or guardian support other children? (Y or N)
  20 Primary and SOLA retained (Line 10 x Line 18B + Line 11) 20    
   
Does the parent support children in more than 2 household?
  21 Itemized Primary (Line 12) 21  
    Number     Children of this Union     Number   22 A - Parenting Time Percentage (80 - 124 Overnights, 10%; 125-163, 30%) 22A  
   
How many child of this union reside primarily in each household?
  B - Parenting Time Adjustment (Line 22A x other parent's Line 20) B  
   
How many children of this union reside in shared placement?
  23 A - Does the parent support children in 3 or more households? (Yes or No) 23A    
    Number     Parenting Time Credit     Number   B - Self Support Protection % (If Line 23A = Yes, then 30%; if No, then 45%) B  
   
How many children does this parent visit 80 to 124 overnights?
  C - Self Support Protection (Line 8 x Line 23B) C  
   
How many children does this parent visit 125 to 163 overnights?
  24 Net Obligation (Line 19 minus Lines 20, 21 and 22B but not more than 23C) 24  
                      Notes: