Fill and Sign the In 2 County Form

Revised December 2016 1 of 3 DRS12F SUPERIOR COURT OF ARIZONA IN (2) _____________________COUNTY PARENT’S WORKSHEET FOR CHILD SUPPORT (3) ___________________________________ Name of Petitioner )))(5) Case No. _______________________(4) ___________________________________Name of Respondent))(6) ATLAS No. _____________________(7) Name of parent filing: __________________________________ _ (8) Date prepared: ___________________________________(9) In this case, I am the [ ] Petitioner [ ] Respondent [ ] Represented by Attorney(10) Time-sharing arrangement: [ ] Essentially equal [ ] Mostly with Father [ ] Mostly with MotherPresumptive termination date _________________ Actual termination date _________________Youngest grade ______ Number of minor children ______ Number of children age 12 or over ______ (12) Gros s Inc om e f igur es for the OTHE R PAR ENT a re:[ ] ACTUAL, with proof, such as a recent W2 or pay stub attached, or other party’s signed statement. [ ] ESTIMATED, based on facts or knowledge of pay before promotion or of others in similar job. [ ] ATTRIBUTED , based on what other party could and should be earning (see Guidelines 5e). For Clerk Use Only (1) Name of Person Filing:Your Address: Your City, State, Zip Code:Your Telephone Number:ATLAS Number (if applicable):Attorney Bar Number (if applicable):Representing: Self (Without an Attorney) Or Attorney for Petitioner Respondent (11) Child(ren)’s names (First, middle initial, and last name) Date of birth Age Case No._____________________ Revised December 2016 2 of 3 DRS12FFath erM oth erGross Monthly Income(13)$ $ Spousal maintenance paid(14)$-$-Spousal maintenance received(15)$+$+Custodial parent of other children subject of court order(s) [ ] Father [ ] Mother (16)$- $- Court-ordered child support paid for children of other relationships (17)$- $- Other natural or adopted children not subject of court order(s) [ ] Father [ ] Mother (18)$- $- Standard deduction $- $- Alternate Deduction (only if less than standard deduction) $- $- Adjusted Gross Monthly Income (19)$ $ Combined Adjusted Gross Income (20) $ Basic Child Support Obligation for [ ] children(21) $ Additions: Adjusted for [ ] children over age 12 at [ ]% (22) $ Medical, dental and vision insurance paid(23)$ $ Monthly childcare costs for [ ] child(ren)(24)$ $ Less federal tax credit allowed to custodian at [ ]% $ $ Extra education expenses paid (25)$ $ Extraordinary (gifted or handicapped) child expenses paid (26)$ $ Subtotal(27)$ $ Total Adjustments for Costs(28) $ Total Child Support Obligation(29) $ Each parent’s proportionate percentage of combined income(30) __________% __________%Each parent’s proportionate share of the total support obligation(31)$ $ Less paying parent’s costs(32)$ $ Costs associated with parenting time: Table A [ ]Table B [ ]No. of parenting days ______ Line (21) x adjustment percentage ______%(33)$ $ Adjustments subtotal(34)$ $ Preliminary Child Support Amount (35)$ $ Case No._____________________ Revised December 2016 3 of 3 DRS12FFath erM oth erSelf-Support Reserve Test for PayorLine (19) $ Less paid arrears $Less $1,115(36)$ $ Child support amount to be paid by: [ ] Father [ ] Mother (37)$ $ Travel related to parenting time(38) __________% __________%Medical, dental, and vision costs not paid by insurance(39) __________% __________%