Washington Child Support Form

Washington State Child Support Schedule Worksheets

Proposed by (name) State of WA Other

Signed by the Judicial/Reviewing Officer

County Case No.

Child/ren and Age/s:

Parents’ names: (Column 1) (Column 2)

Part I: Income (see Instructions, page 6)

1. Gross Monthly Income

a. Wages and Salaries

b. Interest and Dividend Income

c. Business Income

d. Maintenance Received

e. Other Income

f. Imputed Income

g. Total Gross Monthly Income

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

3. Monthly Net Income

4. Combined Monthly Net Income

5. Basic Child Support Obligation

Child #1 Child #2 Child #3

Child #4 Child #5 Total

6. Proportional Share of Income

Part II: Basic Child Support Obligation (see Instructions, page 7)

7. Each Parent’s Basic Child Support Obligation

8. Calculating low income limitations

Self-Support Reserve

a. Is Combined Net Income Less Than $1,000? Yes

b. Is Monthly Net Income Less Than Self-Support Reserve? Yes

c. Is Monthly Net Income equal to or more than Self-Support Reserve? Yes

9. Each parent’s basic child support obligation after calculating applicable limitations

Part III: Health Care, Day Care, and Special Child Rearing Expenses (see Instructions, page 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

d. Combined Monthly Health Care Expenses

11. Day Care and Special Expenses

a. Day Care Expenses

b. Education Expenses

c. Long Distance Transportation Expenses

d. Other Special Expenses (describe)

e. Total Day Care and Special Expenses

12. Combined Monthly Total Day Care and Special Expenses

13. Total Health Care, Day Care, and Special Expenses

14. Each Parent’s Obligation for Health Care, Day Care, and Special Expenses

Part IV: Gross Child Support Obligation

15. Gross Child Support Obligation

Part V: Child Support Credits (see Instructions, page 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

Part VI: Standard Calculation/Presumptive Transfer Payment (see Instructions, page 9)

17. Standard Calculation

Part VII: Additional Informational Calculations

18. 45% of each parent’s net income from line 3

19. 25% of each parent’s basic support obligation from line 9

Part VIII: Additional Factors for Consideration (see Instructions, page 9)

20. Household Assets

a. Real Estate

b. Investments

c. Vehicles and Boats

d. Bank Accounts and Cash

e. Retirement Accounts

f. Other (describe)

21. Household Debt

22. Other Household Income

a. Income Of Current Spouse or Domestic Partner

Name

Name

b. Income Of Other Adults In Household

Name

Name

c. Gross income from overtime or from second jobs the party is asking the court to exclude

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

26. Other Factors For Consideration

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 Washington, the information contained in these Worksheets is complete, true, and correct.

This worksheet has been certified by the State of Washington Administrative Office of the Courts.

Photocopying of the worksheet is permitted.