Washington State, County of Mason Child Support Schedule
□ Proposed by □ (name) ………………………………. □ State of WA (CSWP)
Or, □ Signed by the Judicial/Reviewing 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, 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 (add lines 1 a through 1 (f) $ $
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
Number of children: ……. × $ ……. Per child
(enter total amount in box
$
6. Proportional Share of Income (divide line 3 by line 4 for each
parent)
$ $
Part II: Basic Child
7. Each Parent’s Basic Child Support Obligation without $ $
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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 for
a one-person family)
$
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 more than Self-Support
Reserve? If yes, for each parent subtract the self-support
reserve from line 3. If 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, 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 (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 Expenses $ $
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 10d plus
line 12)
$
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 $ $
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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) $ $
Part V: Child Support Credits (see Instructions, page 9)
Column 1 Column 2
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 16a through 16c)
$
$
$
$
Part VI: Standard Calculation/ Presumptive Transfer Payment (see Instructions, page 9)
17. Standard Calculation (line 15 minus line 16d or $50 per child
whichever is greater)
$ $
Part VII: Additional Information Calculations
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 Accounts $ $
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 the Other Adults In Household
Name ……………………………………..
Name …………………………………….
$
$
$
$
c. Gross income from overtime or from second jobs the party is
asking the court to exclude per Instructions, page 8
…………………………………………………….
$ $
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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, Monthly Child Support Ordered for Other Children
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
Signatures and Dates
I declare, under penalty of perjury under the laws of the State of Wahington, the information contained
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in these Worksheets is complete, true, and correct.
……………………………………….. …………………………………..
Parent’s Signature (Column 1) Parent’s Signature (Column 1)
………………………………………… ………………………………………….
Date City Date City
………………………………………….. ……………………………………
Judicial/ Reviewing Officer Date
This worksheet has been certified by the State of Washington Administration Office of the
courts.
Photocopying of the worksheet is permitted
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