Delaware Report

The Family Court of the State of Delaware

CHILD SUPPORT FINANCIAL DISCLOSURE REPORT

Form16(a) Rev 2/19

1. Personal Information

The child(ren) for whom support is sought is(are):

2. Documentation

Bring copies of your last three pay stubs from your most recent employment and your most recent tax return with all schedules and W-2 statements to every mediation conference and hearing. If self-employed, Schedule C, Schedule SE, and all 1099 forms from your last tax return are also required. Other documents may be needed depending on the facts of your case.

Attachment checklist:

3. Employment and Training

What is your current occupation? Date employment began:

Current Employers Name and address:

Federal Employer Identification Number (EIN) as stated on W-2, 1099, or pay stub:

Military pay grade (if applicable): How many hours do you work per week?

If unemployed or working less than 35 hours per week, explain circumstances:

Do you have any degrees, diplomas, certificates or vocational licenses? If applicable, provide the field of study or specialization.

If unemployed (or employed less than 35 hours per week), what was your last full time Occupation?

Former Employers Name: Date employment ended:

Reason for leaving: Rate of pay: $ per

Did you qualify for unemployment compensation? Yes No Did not apply

4. Income

5. Deductions

All mandatory pension contributions are allowed. Voluntary pension contributions are allowed to the extent mandatory contributions do not exceed 5% of income. Taxes withheld from pay are not deductible for child support because income tax liability is built into the Self Support Allowance, Standard of Living Adjustment, and Self Support Protection percentages. Alimony and life insurance are deductible if documented by a Court order.

6. Health Insurance

What is the TOTAL out-of-pocket premium cost of all types of health insurance:

You are currently paying for that covers BOTH you and the children? per

You are currently paying for that covers you BUT NOT the children)? per

Covering the children through your current spouse’s employment? per

If you are NOT providing insurance, is coverage for the children available through your employment? Yes No

If ‘yes’, what would the out-of-pocket cost be to cover you and the children? per

What is the name of the major medical insurance company?

7. Other Dependent Children

List any other children (but not stepchildren) who reside in your household, or for whom you either are under an order to pay support or can prove a regular pattern of financial support.

8. Additional Primary Expenses

Childcare expenses incurred to enable either parent to work are included in the calculation. Private school tuition and expenses receive consideration under some circumstances.

9. Shared Placement/Parenting Time Adjustment

Support will be calculated in reliance on the most recent custody, visitation or guardianship order or agreement. If there is no court order or agreement establishing the number of overnights with each parent, or if actual practice differs from the order or agreement, the actual number of overnights must be proven by clear and convincing evidence.

Is there a custody, visitation, or guardianship order agreement? Yes No

Placement of the children is with: Father Mother Shared (164+ annual overnights in each h/h)

How many overnights are the children with the non-placement parent? less than 80 80 to 124 125 to 163

State of Delaware, County of New Castle Kent Sussex

SIGNED AND SWORN (OR AFFIRMED) before me this day of , .