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WSCSS-Worksheets - Mandatory (CSW/CSWP) 05 /201 6 Page 1 of 5 Washington State Child Support Schedule Worksheets Proposed by (name) ___ _______________ _ State of W A Other _______________ . (CSW P) Or , Signed by the Judicial/Reviewi ng Officer. (CSW ) County Case No . Child/ren and Age/s: Parents’ names: (Column 1) (Column 2) Column 1 Column 2 Part I: Income (see Instructions, p age 6) 1. Gross Monthly Income a. W ages and Salaries $ $ b. Interest and Dividend Income $ $ c. Business Income $ $ d. Maintenance Received $ $ e. Other Income $ $ f. Imputed Income $ $ g. Total Gross Monthly Income (add lines 1a through 1f) $ $ 2. Monthly Deductions from Gross Income a. Income Taxes (Federal and State) $ $ b. FICA (Soc. Sec.+ Medicare )/Self-Employment Taxes $ $ c. State Industrial Insurance Deductions $ $ d. Mandatory Union/Professional Dues $ $ e. Mandatory Pension Plan Payments $ $ f. Voluntary Retirement Contributions $ $ g. Maintenance Paid $ $ h. Normal Business Expenses $ $ i. Total Deductions from Gross Income (add lines 2a through 2h) $ $ 3. Monthly Net Income (line 1g minus 2i) $ $ 4. Combined Monthly Net Income (add both parents’ monthly net incomes from line 3) $ 5. Basic Child Support Obligation (enter total amount in box ) Child #1 _________ Child #3 __________ Child #5 __________ Child #2 _________ Child #4 __________ $ 6. Proportional Share of Income (divide line 3 by line 4 for each parent) . . WSCSS-Worksheets - Mandatory (CSW/CSWP) 05 /201 6 Page 2 of 5 Column 1 Column 2 Part II: Basic Child Support Obligation (see Instructions, p age 7) 7. Each Parent’s Basic Child Support Obligation without consideration of low income limitations. (Multiply each number on line 6 by line 5.) $ $ 8. Calculating low income limitations: Fill in only those that apply. Self-Support Reserve: (125% of the Federal Poverty Guideline.) $ a. Is Combined Net Income Less Than $1,000 ? If yes , for each parent enter the presumptive $50 per child. $ $ b. Is Monthly Net Income Less Than Self-Support Reserve ? If yes , for that parent enter the presumptive $50 per child. $ $ c. Is Monthly Net Income equal to or more t han Self-Support Reserve ? If yes , for each parent subtract the self-support reserve from line 3. If that amount is less than line 7, enter that amount or the presumptive $50 per child, whichever is greater. $ $ 9. Each parent’s basic child support obligation after calculating applicable limitations. For each parent, enter the lowest amount from line 7, 8a - 8c, but not less than the presumptive $50 per child. $ $ Part III: Health Care, Day Care, and Special Child Rearing Expenses (see Instructions, p age 8) 10 . Health Care Expenses a. Monthly Health Insurance Premiums Paid for Child(ren) $ $ b. Uninsured Monthly Health Care Expenses Paid for Child(ren) $ $ c. Total Monthly Health Care Expenses (line 10a plus line 10b) $ $ d. Combined Monthly Health Care Expenses (add both parents’ totals from line 10c) $ 11 . Day Care and Special Expenses a. Day Care Expens es $ $ b. Education Expenses $ $ c. Long Distance Transportation Expenses $ $ d. Other Special Expenses (describe) $ $ $ $ $ $ $ $ e. Total Day Care and Special Expenses (add lines 11a through 11d) $ $ 12. Combined Monthly Total Day Care and Special Expenses (add both parents’ day care and special expenses from line 11e) $ 13 . Total Health Care, Day Care, and Special Expenses (line 10d plus line 12) $ 14 . Each Parent’ s Obligation for Health Care, Day Care, and Special Expenses (multiply each number on line 6 by line 13) $ $ Part IV: Gross Child Support Obligation 15 . Gross Child Support Obligation (line 9 plus line 14) $ $ WSCSS-Worksheets - Mandatory (CSW/CSWP) 05 /201 6 Page 3 of 5 Column 1 Column 2 Part V: Child Support Credits (see Instructions, p age 9) 16. Child Support Credits a. Monthly Health Care Expenses Credit $ $ b. Day Care and Special Expenses Credit $ $ c. Other Ordinary Expenses Credit (describe) $ $ d. Total Support Credits (add lines 16 a through 16c) $ $ Part VI: Standard Calculation/Presumptive Transfer Payment (see Instructions, p age 9) 17. Standard Calculation (line 15 minus line 16d or $50 per child whichever is greater) $ $ Part VII: Additional Informational Calculations 18. 45 % of each parent’s net income from line 3 (.45 x amount from line 3 for each parent) $ $ 19. 25% of each parent’s basic support obligation from line 9 (.25 x amount from line 9 for each parent) $ $ Part VIII: Additional Factors for Consideration (see Instructions, p age 9) 20 . Household Assets (List the estimated present value of all major household assets.) a. Real Estate $ $ b. Investments $ $ c. Vehicles and Boats $ $ d. Bank Accounts and Cash $ $ e. Retirement Accou nts $ $ f. Other (describe) $ $ $ $ 21. Household Debt (List liens against household assets, extraordinary debt.) $ $ $ $ $ $ $ $ $ $ 22 . Other Household Income a. Income Of Current Spouse or Domestic Partner (if not the other parent of this action ) Name _________________ _________________________ Name _________________ _________________________ $ $ $ $ b. Income Of Other Adults In Household Name _________________ _________________________ Name _________________ _________________________ $ $ $ $ WSCSS-Worksheets - Mandatory (CSW/CSWP) 05 /201 6 Page 4 of 5 Column 1 Column 2 c. Gross income from overtime or from second jobs the party is asking the court to exclude per Instructions , page 8 _________________________________________________ $ $ d. Income Of Child(ren) (if considered extraordinary) Name ________________________________ __________ Name _________________ _________________________ $ $ $ $ e. Income From Child Support Name _________________ _________________________ Name _________________ _________________________ $ $ $ $ f. Income From Assistance Programs Program _______________ _________________________ Program _ ______________________________________ _ $ $ $ $ g. Other Income (describe) ________________________________________________ ________________________________________________ $ $ $ $ 23. Non-Recurring Income (describe) _________________________________________________ _________________________________________________ $ $ $ $ 24. Child Support Owed, Monthly, for Biological or Legal Child(ren) Name/age: _____________________________ Paid [ ] Yes [ ] No $ $ Name/age: _______________________ ______ Paid [ ] Yes [ ] No $ $ Name/age: _____________________________ Paid [ ] Yes [ ] No $ $ 25. Other Child(ren) Living In Each Household (First name(s) and age(s)) 26. Other Factors For Consideration WSCSS-Worksheets - Mandatory (CSW/CSWP) 05 /201 6 Page 5 of 5 Other Factors for Consideration (continued) (attach additional pages as necessary) Signature and Dates I declare, under penalty of perjury under the laws of the State of W ashington, the information contained in these W orksheets is complete, true, and correct. Parent’s Signature (Column 1) Parent’s Signature (Column 2) Date City Date City ________________________________________ _______________________________________ Judicial/Reviewing Officer Date This worksheet has been certified by the State of Washington Administrative Office of the Courts . Photocopying of the worksheet is permitted .