Fill and Sign the Wscss Child Support Form

Child Support Order Summary Report Father’s Name: _______________________________ Mother’s Name: ______________________________ Cause Number: _______________________________ County: ____________________________________ Date of Order: _______________________________ Summary Report Filed by:  Father  Mother 1. Type of Order (check one):  Superior Court  Administrative Law Judge 2. Was the order for child support:  Original Order for Support  Order Modifying Support 3. Number of children of the parties: ______ 4. List each child’s age below: Child 1 _____ Child 2 _____ Child 3 _____ Child 4 _____ Complete lines 5-13 using the amounts entered on the child support worksheets signed by the judge/reviewing officer. 5. Father’s monthly net income (Support Worksheet Page 1, Line 3) $______________ 6. Mother’s monthly net income (Support Worksheet Page 1, Line 3) $______________ 7. List the basic child support obligation for each child (from Worksheet, Page 1, Line 5, individual amounts) Child 1 __________ Child 2 __________ Child 3 __________ Child 4 __________ 8. Health Care Expenses (Support Worksheet Page 1, Line 8f) $_____________ 9. Day Care and Special Expenses (Support Worksheet Page 2, Line 9) a. Day Care Expenses $_____________ b. Education Expenses $_____________ c. Long Distance Transportation Expenses $_____________ d. Other _______________________________ $_____________ e. Other _______________________________ $_____________ 10.a. Father’s standard calculation support obligation (Support Worksheet Page 3, Line 15) $_____________ b. Mother’s standard calculation support obligation (Support Worksheet Page 3, Line 15) $_____________ Actual Transfer Payment Ordered and Deviation (if any) 11. Which Parent is Payor?  Father  Mother 12. Transfer Payment Amount Ordered by Court $_____________ 13. a. If the Court deviated (amount from Line 12 differs from amount on Line 10 for the Payor), was the deviation due to:  Child Needs  Parental Factors b. If the Court deviated, what were the reasons stated by the Court for the deviation? ___________________________________________________________________________________________ ___________________________________________________________________________________________ 14. a. Was post-secondary education provided for?  Yes  No b. If provided for, was a dollar amount ordered?  Yes  No c. If a dollar amount was ordered, enter Payor’s amount $______________ Answer remaining questions only if this was an order modifying support. 15. Total amount of the support transfer payment on the previous order: $______________ 16. Which parent paid the transfer payment in the previous order?  Father  Mother 17. Was the change in the support transfer payment, if any, phased in?  Yes  No 18. The change in the support order was due to: (check all applicable categories)  Change in parent income  Change in residential schedule  Age of children  Change in support schedule  Other WSCSS/Summary Report 06-10-04