Fill and Sign the Form16a

Form16(a)Rev 2/19 1 of 2 The Family Court of the State of DelawareCHILD 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): NameDate of BirthNameDate of Birth NameDate of BirthNameDate 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 AmountOther incomeAmount 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 Form16(a)Rev 2/19 2 of 2 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 AgeLives with: Name AgeLives 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 5.Deductions