Fill and Sign the Insurance Premium Form

INSURANCE PREMIUM AND CHILD CARE ADJUSTMENT WORKSHEET INSURANCE ADJUSTMENT Use this section of the worksheet to calculate how the children's medical insurance premium expenses change the amount the obligor pays to the obligee. If the OBLIGOR parent is ordered to maintain medical insurance for the children complete this section. A. Enter the amount of the children's portion of the medical insurance premium actually paid by the obligator. $       B. Multiply Line A. by .50 to obtain the obligee's share of the premium. $       C. Subtract the amount in Line B. from the base child support award to obtain the amount the obligor pays to the obligee for the months the premium is actually paid. Enter the result here. $       If the OBLIGEE parent is ordered to maintain medical insurance for the children complete this section. D. Enter the amount of the children's portion of the medical insurance premium actually paid by the obligee. $       E. Multiply Line D. by .50 to obtain the obligor's share of the premium. $       F. Add the amount in Line E. to the base child support award to obtain the amount the obligor pays to the obligee for the months the premium is actually paid. $       No credit or offset is allowed unless the premium is actually paid. If the premium is not paid, the obligor must pay the amount of the base child support award. CHILD CARE ADJUSTMENT Use this section of the worksheet to calculate how the children's child care expenses change the amount the obligor pays to the obligee. G. Enter the average amount of monthly child care expense actually paid by the obligee. $       H. Multiply Line G. by .50 to obtain the obligor's share of the child care expense. Enter the result here. Complete box I, J, or K below. $       I. If neither parent is maintaining insurance , add the amount in Line H. tot he base child support award to obtain the amount the obligor pays to the obligee for the months the child care expense is incurred. Enter the result here. $       J. If the obligor is maintaining insurance, add the amount in Line H. to the amount in Line C. to obtain the amount the obligor pays to the obligee for the months the child care expense is incurred. Enter the result here. $       K. If the obligee is maintaining insurance , add the amount in Line H. to the amount in Line F. to obtain the amount the obligor pays to the obligee for the months the child care expense is incurred. Enter the result here. $       10/94 - 1 - INSTRUCTIONS FOR THE INSURANCE PREMIUM AND CHILD CARE ADJUSTMENT WORKSHEET Line A. Enter the children's portion of the medical insurance premium actually paid by the obligator. Obtain this figure by dividing the premium amount actually paid by the obligor by the number of persons covered by the policy and then multiplying that number by the number of children in this case covered by the policy. Line B. Complete the calculation as directed. Line C. Complete the calculation as directed. The base child support award is found on line 7 of the sole custody worksheet, line 10 of the split custody worksheet and line 11 on the joint custody worksheet. Line D. Enter the children's portion of the medical insurance premium actually paid by the obligee. Obtain this figure by dividing the premium amount actually paid by the obligee by the number of persons covered by the policy and then multiplying that number by the number of children in this case covered by the policy. Line E. Complete the calculation as directed. Line F. Complete the calculation as directed. The base child support award is found on line 7 of the sole custody worksheet, line 10 of the split custody worksheet and line 11 on the joint custody worksheet. Line G. Enter the average amount of monthly child care expense actually paid by the obligee for the children in this case. Line H. Complete the calculation as directed. Line L Complete the calculation as directed. The base child support award is found on line 7 of the sole custody worksheet, line 10 of the split custody worksheet and line 11 of the joint custody worksheet. Line J. Complete the calculation as directed. Line K. Complete the calculation as directed. - 2 -