Father
Mother
Number of children residing with you from this relationship
Age of Children (List oldest first)
Child One
Child Two
Child Three
Child Four
Child Five
under 1 year
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
under 1 year
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
under 1 year
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
under 1 year
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
under 1 year
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Lives with
Father
Mother
Lives with
Father
Mother
Lives with
Father
Mother
Lives with
Father
Mother
Lives with
Father
Mother
% of time with non-custodial parent
Marital Status
Single
Married to Mother
Remarried
Single
Married to Father
Remarried
Do you pay alimony/spousal support to the other parent?
If so, how much?
No
Yes
Please calculate
No
Yes
Please calculate
Tax Filing Status
Single
Married filing joint
Married filing separate
Head of Household/MLA
Single
Married filing joint
Married filing separate
Head of Household/MLA
Number of exemptions (include yourself and others claimed on
tax return, not on W-4)
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Do you pay FICA (Social Security Taxes)?
Yes
No
Yes
No
Gross Monthly Salary Income
Include Monthly
Overtime Report for income not included above?
Include Annual Bonus
Report for income not included above?
Self Employment Monthly Income
Other Taxable Monthly Income
Explain
TANF (Temporary Assistance to Needy Families received from
the government
Other Non-Taxable Monthly Income
Explain (disability, worker's comp, BAH, etc)
New spouse income
Adjustments to Income (ATI)
Spousal Support Paid to
Ex-spouse (Not this relationship)
Child Support Paid by me for
Children from Other Relationship
Health Insurance Monthly
Premiums (paid by you, not your employer)
Itemized Deductions (Total from
1040 Schedule A divided by 12) *The following five amounts should
equal this amount.
*Other Medical Expenses (From 1040 Schedule A divided by 12
for monthly amount)
*Property Tax Expenses (From 1040 Schedule A divided by 12
for monthly amount)
*Deductible Interest Expense (From 1040 Schedule A divided by
12 for monthly amount)
*Charitable Contribution Expense (From 1040 Schedule A
divided by 12 for monthly amount)
*Miscellaneous Itemized (From 1040 Schedule A divided by 12
for monthly amount)
Monthly Required Union Dues
Monthly Mandatory Retirement
Contributions
Hardship Deduction (number of
other children you support, do not include step-children)
Explain
Other Guideline Deductions
Child Support
Add-ons
Father
Mother
Monthly Day Care Costs for
Children of this relationship (do not include normal living expenses)
Monthly Visit, School and
Travel Expenses (not normal expenses incurred while having custody of your
child)
Uninsured Health Expenses of
children from this relationship
Monthly Child Care Costs for
Children of other relationship
Other Information: For instance one parent lives out-of-state,
different visitation for individual children, special
circumstances etc.
