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STATE OF HAWAII FAMILY COURT OF THE CIRCUITSIMPLIFIED CHILD SUPPORT GUIDELINES WORKSHEET As determined by the SIMPLIFIED CHILD SUPPORT CALCULATION TABLECASE NUMBERFC- NO PLAINTIFF/PETITIONER Mother Father VS. DEFENDANTS/RESPONDENT Mother Father This document was prepared by Plaintiff Defendant Atty. For Plaintiff Atty. For Defendant Name Address City, State, Zip Telephone I/We certify that:1. The Custodial Parent is father mother. 2.The Custodial Parent is caring for at least one of the parties’ children under the age of three in the home and not in a day care, and:3.The Custodial Parent’s only income is from needs-based public assistance such as welfare, TANF, general issues assistance, food stamps, SSI, Section 8 Housing, WIC and/or Pell Grant; and 4.The Custodial Parent is not working; and5.The non-custodial parent who is responsible for the child support payments (payor parent) has a total gross monthly income of not more than $1450 per month; and6.No income is to be imputed to either parent. (See General Instructions 11/01/98, page 4)Non-Custodial Parent’s Gross Income per month $ .Number of Children covered under this case for which child support is being calculated CHILD SUPPORT PER THE SIMPLIFIED CHILD SUPPORT CALCULATIONS TABLE:TOTAL AMOUNT PER CHILD $ TOTAL AMOUNT OF CHILD SUPPORT PER MONTH $ (See the Simplified Child Support Calculation Table (Attachment A-2))I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECTFather DateMotherDateFor Court Use Only SIMPLIFIED 11/98 ATTACHMETN A-1 SIMPLIFIED CHILD SUPPORT CALCULATION TABLE Payors’sIncome: From To1 child 2 childrenper child/total3 childrenper child/total4 childrenper child/total5 childrenper child/total$0$825 $50$50/$100$50/$150$50/$200$50/$250 $826$850 $60$50/$100$50/$150$50/$200$50/$250 $851$875 $70$50/$100$50/$150$50/$200$50/$250 $876$900 $70$50/$100$50/$150$50/$200$50/$250 $901$925 $80$50/$100$50/$150$50/$200$50/$250 $926$950 $90$50/$100$50/$150$50/$200$50/$250 $951$975 $100$50/$100$50/$150$50/$200$50/$250 $976$1000 $110$55/$100$50/$150$50/$200$50/$250 $1001$1025 $110$55/$100$50/$150$50/$200$50/$250 $1026$1050 $120$60/$120$50/$150$50/$200$50/$250 $1051$1075 $130$65/$130$50/$150$50/$200$50/$250 $1076$1100 $140$70/$140$50/$150$50/$200$50/$250 $1101$1125 $150$75/$150$50/$150$50/$200$50/$250 $1126$1150 $150$75/$150$50/$150$50/$200$50/$250 $1151$1175 $160$80/$160$53.33/$160$50/$200$50/$250 $1176$1200 $170$85/$170$56.66/$170$50/$200$50/$250 $1201$1225 $180$90/$180$60/$180$50/$200$50/$250 $1226$1250 $190$95/$190$63.33/$190$50/$200$50/$250 $1251$1275 $190$95/$190$63.33/$190$50/$200$50/$250 $1276$1300 $200$100/$200$66.66/$200$50/$200$50/$250 $1301$1325 $210$105/$210$70/$210$52.50/$210$50/$250 $1326$1350 $220$110/$220$73.33/$220$55/$220$50/$250 $1351$1375 $230$115/$230$76.66/$230$57.50/$230$50/$250 $1376$1400 $230$115/$230$76.66/$230$57.50/$230$50/$250 $1401$1425 $240$120/$240$80/$240$60/$240$50/$250 $1426$1450 $250$125/$250$83.33/$250$62.50$250$50/$250 ATTACHMENT A-2 STATE OF HAWAII FAMILY COURT OF THE CIRCUIT CHILD SUPPORT GUIDELINES WORKSHEET CASE NUMBERFC- NO PLAINTIFF/PETITIONER Mother Father VS. DEFENDANT/RESPONDENT Mother Father This document was prepared by Plaintiff Defendant Atty, for Plaintiff Atty. for Defendant Name Address City, State, Zip TelephoneLine 1BASE PRIMARY SUPPORT $250 X (# of children) 2 Plus Monthly Child Care Expenses+ 3 Plus Monthly Health/Dental Insurance for the Child(ren)+ 4 PRIMARY SUPPORT NEED (add lines 1,2 and 3)=FATHER (A)MOTHER (B)TOTAL (C) 5 Parent’s SOLA Income ( from Table)+= 6 Less PRIMARY SOURCE NEED (from Line 4) 7 Parent’s Net SOLA Income (line 5 – line 6) 8 SOLA Percentage, 10% per child, up to 30%X % 9 SOLA OBLIGATION (line 7 x line 8) 10 TOTAL SUPPORT NEED (line 4 + line 9)FATHER (A)MOTHER (B)TOTAL (C) 11 Monthly Gross Income+= 12 Monthly Net Income (from Table) += 13 Income Percentage (line 12(A) / line 12(C)) or (line 12(B)/ line 12(C)) %% 14 Support Payable By Each Parent (line 10) x Parent’s (line 13) % 15 Less Monthly Child Care Expenses for Parent Who Pays- 16 Less Monthly Health Insurance Cost Parent Who Pays- 17 REMAINING CHILD SUPPORT PAYABLE BY EACH PARENT (Round to nearest 10.00) 18 Mother Father pays to Mother Father in child support for a total of $ per month ($ per child per month). Mother Father pays health insurance. Mother Father pays child care expenses. I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT.Father DateMother DateFor exceptional circumstances see attached Exceptional Circumstances Form.For joint physical custody calculations or visitation 143 days or over per year, see Child Support.Guidelines. Worksheet For Joint Custody/Extensive Visitation and enter amounts on line 18.For Court Use Only CSG 11/98 ATTACHMENT B – 1 STATE OF HAWAII FAMILY COURT OF THE CIRCUIT CHILD SUPPORT GUIDELINES WORKSHEET FOR JOINT CUSTODY/ EXTENSIVE VISITATIONCASE NUMBERFC- NO PLAINTIFF/PETITIONER Mother Father VS. DEFENDANT/RESPONDENT Mother Father This document was prepared by Plaintiff Defendant Atty, for Plaintiff Atty. for Defendant Name Address City, State, Zip TelephoneLINE JOINT CUSTODY CALCULATION FATHER (A)MOTHER (B) (C)1 SUPPORT (From Child Support Guidelines Worksheet Line 17) no less than $50/child 2 YEARLY SUPPORT OBLIGATOIN UNDER JOINT CUSTODY[Line 1(A) x 6 months] and [Line 1(B) x 6 months] 3 Difference between lines 2(A) and 2(B) (larger amount – lesser amount) 4 JOINT CUSTODY CHILD SUPPORT = [Line 3(C)/ 12] rounded to nearest $10.00. Enter this amount in either Line 4(A) or Line 4(B) for the parent who has the larger child support obligation from Line 1 above. IF JOINT CUSTODY, STOP HERE AND ENTER AMOUNT FORM LINE 4(A) OR 4(B) OF THIS WORKSHEET TO CHILD SUPPORT GUIDELINES WORKSHEET LINE 18. EXTENSIVE VISITATION CALCULATION The Custodial Parent is Father Mother. The Non-Custodial Parent is Father Mother. The Non-Custodial Parent has visitation of days per year.IF THE NON-CUSTODIAL PARENT HAS OVER 143 DAYS OF VISITATION PER YEAR COMPLETE LINES 5-11 BELOW. 5 REGULAR SUPPORT: Enter the child support obligation for the non-custodial parent from Line 1 above. 6 JOINT CUSTODY CHILD SUPPORT: Enter the amount from Line 4(A) or 4(B) above. 7 Difference: If the child support obligations in line 5 and 6 are for the same parent, then subtract Line 6 from Line 5. [Line 5- Line 6] If the child support obligations in Lines 5 and Lines 6 are for different parents, then add Lines 5 and 6. [Lines 5 + Lines 6] 8 ADJUSTMENT RATE [Line 7 / 40 days] 9 NUMBER OF VISITATION DAYS OVER 143 DAYS PER YEARx10CREDIT FOR DAYS EXCEEDING NORMAL SUPPORT[Line 8 x Line 9]=11EXTENSIVE VISITATION CHILD SUPPORT [NON- CUSTODIAL PARENTS SUPPORT] [Line 5 – Line 10] Roundest to nearest $10.00ENTER SUPPORT AMOUNT FROM LINE 11 OF THIS WORKSHEET LINE 18 ON THE CHILD SUPPORT GUIDELINES WORKSHEET. ATTATCHMENT C STATE OF HAWAII FAMILY COURT OF THE CIRCUITEXCEPTIONAL CIRCUMSTANCES FORM Attached to SIMPLIFIED CHILD SUPPORT CHILD SUPPORT GUIDLELINES GUIDELINESCASE NUMBERFC- NO. The Court should deviate from the Total Monthly Child Support Obligation as calculated because of the following exceptional circumstances:I hereby declare, under penalty of perjury, that I have examined the statement regarding exceptional circumstances and to the best of my knowledge and belief it is true, correct and complete. Dated: Hawaii, . (Signature)