Fill and Sign the Delaware Report PDF Form

Form16(a) Rev 2/19 The Family Court of the State of Delaware CHILD SUPPORT FINANCIAL DISCLOSURE REPORT 1. Personal Information Name       Date       Address       File Number             Petition Number             Home Phone #       Date of birth       Work Phone #       The child(ren) for whom support is sought is(are):                         Name Date of Birth Name Date of Birth                         Name Date of Birth Name Date of Birth 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 : W-2 Form(s) Childcare Custody order Social Security Pay stubs 1099 Form(s) Health Insurance Alimony order Veterans’ Administration Tax Return(s) Schedule C Schedule SE Medical documents       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. High School       GED       Certificate       License       Associates       Bachelors       Graduate       Military       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 Employment Income Amount Other income Amount Primary Job (incl. overtime)       per       Interest, dividends, investments       per       Housing stipend (incl. BAH)       per       Social Security (SSDI or SSR)       per       Food stipend (incl. BAS)       per       Suppl. Security Income (SSI)       per       Geographic cost of living stipend       per       Other retirement or disability       per       Second Job       per       Workers’ Compensation       per       Self Employment (1099)       per       Alimony Received       per       Unemployment Compensation       per       Other:             per       1 of 2 Form16(a) Rev 2/19 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. Deducted from Pay Amount Deducted from Pay Amount Mandatory Pension       % or       per       Health Insurance: Medical       per       Voluntary Pension       % or       per       Dental       per       Union Dues       per       Vision       per       Disability Insurance       per       other       per       Alimony Paid       per       Other mandatory deductions       per       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. Name Age Lives with: Name Age Lives with:                                                                                                             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 . Expense Provider Amount School Year childcare       $       per       Summer childcare             per       Private School             per       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 (dated       /       /       ) 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 ,       .       PRINT NAME OF AFFIANT CLERK OF COURT / NOTARY PUBLIC – 29 Del. C. §4323(a) SIGNATURE OF AFFIANT 2 of 2