Child Supp. Guid. Form 1
Docket No: ___________________ | |||
I. Net Monthly Income of Petitioner (Name) _____________________________ Select one: [ ] Custodial Parent [ ] Noncustodial Parent [ ] Joint Physical Care Petitioner claims _____child/children as tax dependents (list number claime ). | |||
A. Sources and Amounts of Annual Income: __________________________________ __________________________________ plus/minus spousal support payments per rule 9.5(1) | $ ______ $ ______ $ ______ | ||
Total | $ ______ | ||
B. Federal Tax Deduction: Gross annual taxable income ($__________ untaxed) less 1/2 self employment (FICA) tax less federal adjustments to income less personal exemptions: self + _____ (list number of dependents claimed) less standard deduction single [ ] head of household [ ] married filing separate [ ] Net taxable income - federal Federal tax liability (from tax table) Federal tax credit for dependent children | $ ______ <______> <______> <______> <______> $ ______ <______> + ______ | ||
Final federal tax liability | <______> | ||
C. State Tax Deduction: Gross annual taxable income less 1/2 self employment (FICA) tax less state adjustments to income less federal tax liability (adjusted for dependent tax credit) less standard deduction single [ ] head of household [ ] married filing separate [ ] Net taxable income - state State tax liability (from tax table) less personal and dependent credits plus school district surtax ( ______%) | $ ______ <______> <______> <______> <______> $ ______ $ ______ <______> | <______> | |
Final state tax liability | <______> | ||
D. Social Security and Medicare Tax / Mandatory Pension Deduction: Annual earned income Applicable rate (7.65% or 15.3%, as adjusted) Annual Social Security and Medicare tax liability or mandatory pension (For employees not contributing to Social Security, mandatory pension deduction not to exceed the current Social Security and Medicare rate for employees.) | $______ x ______% | ||
E. Other Deductions (Annual): 1. Mandatory occupational license fees 2. Union dues 3. Health insurance premium costs for other children not in the pending matter (See rule 9.5(2) (f).) 4. Cash medical support and prior obligation of child support actually paid pursuant to court or administrative order for other children not in the pending matter. 5. Deduction for _____ additional qualified dependents 6. If a custodial parent, Petitioner's child care expenses (No deduction allowed if variance granted under rule 9.11A.) less federal child care tax credit less state child care tax credit less third party reimbursements | <______> <______> <______> <______> <______> <______> $______ <______> <______> | ||
Actual child care expenses, as defined in rule 9.11A. | <______> | ||
Preliminary Net Annual Income Preliminary Average Monthly Income of Petitioner 7. Monthly cash medical support ordered in this pending action Adjusted Net Monthly Income of Petitioner (Preliminary Average Monthly Income minus Monthly Cash Medical Support ordered in this action.) | $______ $______ <______> $______ | ||
II. Net Monthly Income of Respondent (Name) _____________________ Select one: [ ] Custodial Parent [ ] Noncustodial Parent [ ] Joint Physical Care Respondent claims _____ child/children as tax dependents (list number claimed) | |||
A. Sources and Amounts of Annual Income: _________________________________ _________________________________ plus/minus spousal support payments per rule 9.5(1) | $______ $______ $______ | ||
Total | <______> | ||
B. Federal Tax Deduction: Gross annual taxable income (______________ untaxed) less 1/2 self employment (FICA) tax less federal adjustments to income less personal exemptions: self + ____ (list number of dependents claimed) less standard deduction single [ ] head of household [ ] married filing separate [ ] Net taxable income - federal Federal tax liability (from tax table) Federal tax credit for dependent children | $______ <______> <______> <______> <______> $______ <______> + ______ | ||
Final federal tax liability | <______> | ||
C. State Tax Deduction: Gross annual taxable income less 1/2 self employment (FICA) tax less state adjustments to income less federal tax liability (adjusted for dependent tax credit) less standard deduction single [ ] head of household [ ] married filing separate [ ] Net taxable income - state State tax liability (from tax table) $ ____________ less personal and dependent credits < ____________ > plus school district surtax ( _____ %) | $______ <______> <______> <______> <______> $______ | ||
Final state tax liability | <______> | ||
D. Social Security and Medicare Tax / Mandatory Pension Deduction: Annual earned income Applicable rate (7.65% or 15.3%, as adjusted) Annual Social Security and Medicare tax liability or mandatory pension (For employees not contributing to Social Security, mandatory pension deduction not to exceed the current Social Security and Medicare rate for employees.) | <______> $______ x______% <______> | ||
E. Other Deductions (Annual): 1. Mandatory occupational license fees 2. Union dues 3. Health insurance premium costs for other children not in the pending matter (See rule 9.5(2) (f).) 4. Cash medical support and prior obligation of child support actually paid pursuant to court or administrative order for other children not in the pending matter. 5. Deduction for _____ additional qualified dependents 6. If a custodial parent, Respondent's child care expenses (No deduction allowed if variance granted under rule 9.11A.) less federal child care tax credit less state child care tax credit | <______> <______> <______> <______> <______> <______> $______ <______> | ||
Actual child care expenses, as defined in rule 9.11A Preliminary Net Annual Income Preliminary Average Monthly Income of Respond 7. Monthly cash medical support ordered in this peding action Adjusted Net Monthly Income of Respondent (Preliminary average monthly income minus monthly cash medical support ordered in this action.) | <______> <______> $ ______ $ ______ <______> $ ______ | ||
III. Calculation of the Guideline Amount of Support (If applicable.) | |||
Custodial Parent (CP) [ ] Petitioner [ ] Respondent | Noncustodial Parent (NCP [ ] Petitioner [ ] Respondent | Combined ) | |
A. Adjusted net monthly income | $ ____________ | + $ ____________ | = $ ____________ |
B. Proportional share of income (Also used for uncovered medical expenses.) | |||
C. Number of children for whom support is sought | % ____________ | + % ____________ | = 100% ____________ |
D. Basic support obligation using only ncp's adjusted net monthly income (If low-income adjustment does not apply, enter N/A.) | $ ____________ | ||
E. Basic support obligation using combined adjusted net monthly income (If low-income adjustment applies, enter N/A; see rule 9.3(2) and grid in rule 9.14(2).) | $ ____________ | ||
F. Each parent's share of the basic support obligation using combined incomes (If low-income adjustment applies, enter N/A.) | $ ____________ | $ ____________ | |
G. NCP's basic support obligation before health insurance (NCP's amount from line F or low-income adjustment amount Line D.) | $ ____________ | ||
H. Allowable child(ren)'s portion of health insurance premium (Calculated pursuant to rule 9.14(5).) | $ ____________ | $ ____________ | |
I. Health insurance add-on or deduction from NCP's obligation | + /- | $ ____________ | |
J. Guideline amount of child support for NCP (NCP's line G plus or minus NCP's line I.) Guideline amount of cash medical support (if ordered) | $ ____________ $____________ | ||
III. a. Extraordinary Visitation Credit (Complete only if noncustodial parent's court-ordered visitation exceeds 127 ovrnights per year.) | |||
K. NCP's basic support obligation before health insurance (Amount from NCP's line G.) | $ ____________ | ||
L. Number of court-ordered visitation with the overnights noncustodial parent | ____________ | ||
M. Extraordinary visitation credit percentage | $ ____________ % | ||
N. Extraordinary visitation credit (Line K multiplied by line M.) | $ ____________ | ||
O. Guideline amount of child support after credit for extraordinary visitation (Line J minus line N; not less than $50 for one child, $75 for two children, or $100 for three or more children.) | $ ____________ | ||
III. b.Child Care Expense Variance under rule 9.11A (As agreed by the parties and approved or determined by the court.) | |||
P. NCP's guideline amount of child support (Amount from line J above [or line O, if applicable].) | $ ____________ | ||
Q. Amount of variance for child care expenses | $ ____________ | ||
R. Adjusted amount of child support (Line P plus line Q.) | $ ____________ | ||
IV. Calculation of the Joint (Equally Shared) Physical Care Guideline Amount of Child Support (If applicable.) | |||
Petitioner CP 1 | Respondent CP 2 | Combined | |
A. Adjusted net monthly income | $ ____________ | + $ ____________ | = $ ____________ |
B. Proportional share of income (Also used for uncovered medical expenses.) | % __________ | % __________ | = 100% __________ |
C. Number of children for whom support is sought | __________ | ||
D. Basic support obligation before health insurance (Use line A combined amount to find amount from Schedule of Basic Support Obligations. The low-income adjustment in the shaded area of the schedule does not apply to joint [equally shared] physical care support computations.) | $ ____________ | ||
E. Each parent's basic primary care amount before health insurance (Line B multiplied by line D for each parent.) | $ ____________ | $ ____________ | |
F. Each parent's share of joint physical care support (Line E multiplied by 1.5 for each parent to account for extra costs for two residences.) | $ ____________ | $ ____________ | |
G. Each parent's joint physical care support obligation before health insurance (Line F multiplied by .5 for each parent to account for 50% of time spent with each parent.) | $ ____________ | $ ____________ | |
H. Allowable child(ren)'s portion of health insurance premium* (Calculated pursuant to rule 9.14(5).) *If either parent's net income on line A falls within low-income shaded Area A of the Schedule of Basic Support Obligations, enter N/A. The health insurance adjustment does not apply. | $ ____________ | $ ____________ | |
I. Health insurance add-on to each parent's obligation (see 9.14(3).) | $ ____________ | $ ____________ | |
J. Guideline amount of child support (Each parent's line G plus each parent's line I.) | $ ____________ | $ ____________ | |
K. Net amount of child support for joint physical care after offset (Subtract smaller amount on line J from larger amount on line J. Parent with larger amount on line J pays the other parent the difference, as a method of payment. If either parent receives assistance through the Family Investment Program [FIP], the other parent's obligation reverts to the amount on line J.) | $ ____________ | $ ____________ | |
V. Special Findings | |||
A. Income imputed to Petitioner Income imputed to Respondent | |||
B. Estimated income of Petitioner Estimated income of Respondent | |||
C. Deviations made from Child Support Guidelines | |||
D. Requested amount of child support | $__________ per month | ||
E. Split or divided physical care summary and offset | |||
Guideline amount of child support Petitioner $ ____________ | Guideline amount of child support Respondent $ ____________ | Net amount of child support after offset $ ____________ | |
VI. Changes in Child Support Obligation as Number of Children Entitled to Support Changes (For cases with multiple children based on present income and applicable guidelines calculation method.)
VI.a. Basic Obligation (If applicable.)
Number of children | NCP's basic support obligation (NCP's line G)* | Health insurance addon or deduction (NCP's line I)* | Extraordinary visitation credit (If applicable) (line N)* | Guideline amount of child support (line J or O)* |
______ | $ __________ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ | $ __________ |
*(All line references are to Division III, Calculation of the Guideline Amount of Child Support section of the worksheet.)
VI. b. Joint (Equally Shared) Physical Care Obligation (If applicable.)
Number of children | Guideline amount of child support Petitioner (CP 1 Line J)* | Guideline amount of child support Respondent (CP 2 Line J)* | Net amount of child support for joint physical care after offset (Line K)* |
______ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ |
______ | $ __________ | $ __________ | $ __________ |
*(All line references are to Division IV, Calculation of the Joint (Equally Shared) Physical Care Guideline Amount of Child Support section of the worksheet.)
State of Iowa
ss:
County of ____________________
I certify under the penalty of perjury and pursuant to the laws of the state of Iowa that the preceding is true and correct.
Date: ____________________
__________________________
(Signature)
__________________________
(Printed name)
The undersigned attorney for (Petitioner/Respondent) hereby certifies that this Child Support Guidelines Worksheet was prepared by me or at my direction in good faith reliance upon information available to me at this time.
Date: ______________________________ ____________________________________
(Attorney signature)
Child Supp. Guid. Form 1