Form Dcss 650 - Child Support Guidelines Worksheet - New Hampshire Dcss 650 Department Of Health And Human Services

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STATE OF NEW HAMPSHIRE
DCSS 650
DEPARTMENT OF HEALTH AND HUMAN SERVICES
05/15
DIVISION OF CHILD SUPPORT SERVICES
Child Support Guidelines Worksheet
Court Name:
Case Number:
In the matter of:
and
Child’s Name
DOB
Child’s Name
DOB
1. Total Number of Children
2.
3.
Obligor’s Reasonable Medical Support Obligation
Obligee’s Reasonable Medical Support Obligation
(4% of Obligor’s Monthly Gross Income, rounded to nearest dollar)
(4% of Obligee’s Monthly Gross Income, rounded to nearest dollar)
PAYMENT CALCULATIONS
OBLIGOR
OBLIGEE
COMBINED
NOTE: All income and expenses must be converted to monthly amounts (multiply
(Column 1)
(Column 2)
(Column 3)
weekly amounts by 4.33; bi-weekly amounts by 2.17).
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
Frequency (circle one):
(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.)
Weekly
Bi-Weekly
Monthly
**
**
ROUND THE RESULT TO THE NEAREST WHOLE DOLLAR
Prepared by:
Title:
Date:
RA12
DCSS PR 14-02

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