Fill and Sign the Obligation 4 Monthly Gross Income Form

NHJB-2101-FP (05/30/2015) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH htt p://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) CHILD SUPPORT GUIDELINES WORKSHEET Child's name DOB Child's name DOB 1. Total number of children 2. Obligor’s reasonable medical support obligation (4% monthly gross income) 3. Obligee’s reasonable medical support obligation (4% monthly gross income) PAYMENT CALCULATIONS Note: All income and expenses must be converted to monthly amounts (multiply weekly amounts by 4. 33: bi-weekly amounts by 2.17). OBLIGOR (Column 1) OBLIGEE (Column 2) COMBINED (Column 3) 4. Monthly gross income $ $ 5A. Court/Admin. ordered support for other children $ $ 5B. 50% of actual self-employment taxes paid $ $ 5C. Mandatory retirement $ $ 5D. Actual state income taxes paid $ $ 5E. Allowable child care expenses (obligor) (See LINE 5E instructions) $ 5F. Medical support for children (obligor) $ 5G. Total deductions (Add lines 5A through 5F) $ $ 6. Adjusted monthly gross income (Subtract line 5G from line 4) $ $ $ 7A. Child support guideline amount (From Guideline Calculation Table) $ 7B. Guideline percentage (From Guideline Calculation Table) % 8A. Allowable child care expenses (obligee) (See LINE 8A instructions) $ 8B. Medical support for children (obligee) $ 8C. Total allowable obligee expenses (Add line 8A and 8B) $ 9. Total adjusted monthly gross income $ $ $ 10. Proportional share of income 11. Parental support obligation (Line 10 times line 7A) $ $ ABILITY TO PAY CALCULATION 12. Self-support reserve (From Guideline Calculation Table) $ 13. Income available for support (Subtract line 12 from line 9, column 1) $ 14. Monthly support payable (Enter the smaller of line 11, column 1 or line 13, column 1. If line 13, column 1 is less than $50.00, then a minimum order of $50.00 is entered.) $ 15. Presumptive child support obligation (If weekly, divide line 14 by 4.33; if bi-weekly, divide line 14 by 2.17; if monthly, enter same amount as in line 14.) ** ROUND THE RESULT TO THE NEAREST WHOLE DOLLAR ** $ Frequency (check one): Weekly Bi-Weekly Monthly Prepared by: Title: Date: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00% 100.00% 0.00 0.00 0.00 50.00 Case Name: Case Number: CHILD SUPPORT GUIDELINES WORKSHEET NHJB-2101-FP (05/30/2015) Page 2 of 3 CHILD SUPPORT GUIDELINES WORKSHEET INSTRUCTIONS TOP OF FORM Enter the Court Name, Case Number, the names of the petitioner and respondent, and the names and dates of birth of the children. LINE 1 Enter the total number of children. LINE 2 Enter the Obligor’s reasonable medical support obligation (to determine Obligor’s reasonable medical support obligation, multiply Obligor’s monthly gross inco me by .04 and round to the nearest whole dollar). The Obligor is the person who will pay child support. The monthly gross income for the Obligor is the amount entered in LINE 4, Column 1 (see below). LINE 3 Enter the Obligee’s reasonable medical support obl igation (to determine Obligee’s reasonable medical support obligation, multiply Obligee’s monthly gross inco me by .04 and round to the nearest whole dollar). The Obligee is the person who will receive child support. The monthly gross income for the Obligee is the amount entered in LINE 4, Column 2 (see below). LINE 4 In Columns 1 and 2, enter the total monthly gross in come for the Obligor and Obligee, respectively. Monthly gross income includes all income from any source, w hether earned or unearned, including but not limited to, wages, salary, commissions, tips, annuities, Social Securi ty benefits, trust income, lottery or gambling winnings, interest, dividends, investment income, net rental inco me, self-employment income, alimony, business profits, pension, bonuses and payments from other government pr ograms (excluding public assistance programs such as Temporary Assistance for Needy Families (TANF), Aid to the Permanently and Totally Disabled (APTD), Supplemental Security Income (SSI), Old Age Assistance (OAA), Aid to th e Needy Blind (ANB), Food Stamps and general assistance from a county or town); including, but not limited to, worker’s compensation, veterans’ benefits, unemployment benefits, and disability benefits, provided, however, t hat no income earned at an hourly rate for hours worked, on an occasional or seasonal basis, in excess of 40 hours in any week shall be considered as income for the purpose of determining gro ss income, and provided further that such hourly rate income is earned for actual overtime labor performed by an employee who earns wages at an hourly rate in a trade or industry which traditionally or commonly pays overtime wages, thus excluding professionals, business owners, business partners, self-employed individuals and ot hers who may exercise sufficient control over their income so as to re-characterize payment to themselves to include overtime wages in addition to salary. (NOTE: To compute Monthly Gross Income from weekly income, multiply the weekly amount by 4.33; from bi-weekly income, multiply the bi-weekly income by 2.17.) LINE 5A Enter any court-ordered or adm inistratively-ordered support for children or adults not subject to this order actually paid by the Obligor (in Column 1) and/or the Obligee (in Column 2). LINE 5B Enter 50% of the actual amount of self-employment tax paid by the Obligor (in Column 1) and/or the Obligee (in Column 2). LINE 5C Enter any mandatory retirement contributions paid by the Obligor (in Column 1) and by the Obligee (in Column 2). NOTE: Only payments which are re quired by the employer may be entered. LINE 5D Enter any actual state income taxes paid by t he Obligor (in Column 1) and the Obligee (in Column 2). LINE 5E Enter allowable work-related child care expenses paid by the Obligor in Column 1. Allowable work-related child care expenses means actual child care expenses for the children to whom the order applies, which are incurred as a result of the Obligor’s employment, or due to the Ob ligor’s participation in education or training activities associated with acquiring or maintaining work/job skills. LINE 5F Enter the actual amount paid by the Obligor for addi ng the children to whom the order applies to existing health insurance coverage, or the difference between individual and family coverage, in Column 1. LINE 5G Enter the total allowable deductions for the Obligor (in Column 1) and for the Obligee (in Column 2). NOTE: The Obligor’s total allowable deductions equal the sum of LINES 5A, Column 1 – 5F, Column 1. The Obligee’s total allowable deductions equal the sum of LINES 5A, Column2 – 5F, Column 2. LINE 6 Subtract LINE 5G, Column 1, from LINE 4, Column 1, and enter the result in Column 1. Subtract LINE 5G, Column 2, from LINE 4, Column 2, and enter the result in Column 2. Add Column 1 and Column 2, and enter the result in Column 3. LINE 7A From the Child Support Gui deline Calculation Table, find the line/row containing the Combined Adjusted Monthly Gross Income. Where this row intersects the Column for the number of children to whom this order applies, find the Guideline Amount. Enter this amount in Column 3. LINE 7B From the same line/row of the Child Support Guidel ine Calculation Table, find the appropriate % of Net amount for the number of children to whom this order applies. Enter the percentage in Column 3. Case Name: Case Number: CHILD SUPPORT GUIDELINES WORKSHEET NHJB-2101-FP (05/30/2015) Page 3 of 3 LINE 8A Enter any allowable work-related child care expenses paid by the Obligee in Column 2. Allowable work-related child care expenses means actual child care expenses for the children to whom the order applies, which are incurred as a result of the Obligee’s employment, or due to the Obligee’s participation in education or training activities associated with acqui ring or maintaining work/job skills. LINE 8B Enter the actual amount paid by the Obligee for adding the children to whom this order applies to existing health insurance coverage, or the difference between individual and family coverage, in Column 2. LINE 8C Enter the sum of LINE 8A, Column 2 and LINE 8B, Column 2. LINE 9 Enter the amount in LINE 6, Column 1, in Column 1. Subtract LINE 8C, Column 2, from LINE 6, Column 2, and enter the result in Column 2. Add Column 1 and Column 2, and enter the result in Column 3. LINE 10 Divide LINE 9, Column 1, by LINE 9, Column 3 and enter the result in Column 1. Divide LINE 9, Column 2, by LINE 9, Column 3 and enter the result in Column 2. LINE 11 Multiply LINE 10, Column 1, by LINE 7A, Column 3 and enter the result in Column 1. Multiply LINE 10, Column 2, by LINE 7A, Column 3, and enter the result in Column 2. LINE 12 Enter the self-support reserve amount (115 percent of the poverty level fo r a household of one) as published at the top left corner of each page of the Child Support Guideline Calculation Table. LINE 13 Subtract LINE 12, Column 1 from LINE 9, Column 1 and enter the result in Column 1. LINE 14 Enter the smaller of LINE 11, Column 1, or LINE 13, Column 1. If LINE 13, Column 1, is less than $50.00, enter $50.00 in Column 1 . LINE 15 Enter the presumptive child support obligation amount in Column 1. For weekly obligations, divide LINE 14 by 4.33 and enter the result in Column 1. For bi-weekly ob ligations, divide LINE 14 by 2.17 and enter the result in Column 1. For monthly obligations, enter the amount in LINE 14. ROUND THE RESULT TO THE NEAREST WHOLE DOLLAR, and circle the appropriate frequency. The amount entered in Column 1 must not be lower than $50.00 per month.