Parents Worksheet For Child Support Amount {DRS12f}

(1) Name of Person Filing: Phone Number(s): (IF) Attorney, Name: Atty. Email: / Bar No.: Atty. Phone: For Clerk's use only In this case, I am [ ] Petitioner or [ ] Respondent or [ ] represented by Attorney SUPERIOR COURT OF ARIZONA IN YAVAPAI COUNTY PARENT'S WORKSHEET FOR CHILD SUPPORT (2) Petitioner (3) Respondent (5) Total Number of Children: (6) Parent with Primary Custody: (7) Parent who is filing this form: [ ] Father [ ] Father [ ] Mother [ ] Mother (4) Case No. (4) ATLAS No. 1300DO (8) Gross Income figures for the OTHER PARENT are: [ ] ACTUAL, with proof, such as a recent W2 or pay stub attached, or other party's signed statement. [ ] ESTIMATED, based on facts or knowledge of pay before promotion or of others in similar job. [ ] ATTRIBUTED, based on what other party could and should be earning (see Guidelines 5e). FATHER Gross Income (Pre-tax income before deductions) Spousal Maintenance Paid Spousal Maintenance Received Child Support Paid/Contributed Other Support of Children Paid Adjusted Gross Income Combined Adjusted Gross Income Basic Child Support Obligation Plus Costs for: Medical/Dental/Vision Insurance Childcare Education Expenses Extraordinary/Special Needs Child Expense No. of Children Age 12 or Over Adjustment % Total Adjustments for Costs Total Child Support Obligation Superior Court of Arizona in Yavapai County Updated December 2013 Page 1 of 2 MOTHER (9) (10) (11) (12) (13) $ $$+ $$- $ $$+ $$$ (15) $ (16) $ $ $ $ $ (21) $ (22) $ (23) $ (14) $ (17) (18) (19) (20) $ $ $ $ DRS12f American LegalNet, Inc. www.FormsWorkFlow.com Case No. 1300DO FATHER Each Parent's % of Combined Income % (24) MOTHER % Each Parent's Share of Tot. Support Obligation $ (25) $ Adjustment for Non Custodial Parent's Costs Associated with Parenting Time Using [ ] Table A [ ] Table B (26) No. of Days x Line (16) $ (Basic Child Support Obligation) = % Adjustment (from table) $ $ $ $ $ $ $ (27) $ (28) $ (29) $ (30) $ (31) $ (32) $ (33) $ Less Noncustodial Parent's Costs for: Medical/Dental/Vision Insurance* Childcare * Education Expenses * Extraordinary/Special Needs Child Expenses * Adjustments Subtotal Preliminary Child Support Amount *Subtract here ONLY if ADDED-IN items 17-20 above Self Support Reserve Test for Parent Who Will Pay Amount from Line (14) $ (Adj. Gross Income) Minus Reserve Amount -$ 903.00 = Child Support to be Paid by: [ ] Father [ ] Mother Share of Travel Expenses Related to Parenting Time (Only for expenses related to travel over 100 miles, one way) $ $ (34) $ (35) $ % % (36) (37) % % Share of Medical/Dental/Vision Costs Not Paid by Insurance I declare under penalty of perjury that the foregoing is true and correct. Executed on: Date Superior Court of Arizona in Yavapai County Updated December 2013 Page 2 of 2 Signature of Parent DRS12f American LegalNet, Inc. www.FormsWorkFlow.com