IN THE DISTRICT COURT OF JOHNSON COUNTY, KANSAS CIVIL COURT DEPARTMENT In the matter of the Marriage of: John

Q. Smith and Susie Q. Smith

Case No. 12CV1212 Court 12 CHILD SUPPORT WORKSHEET OF PETITIONER

MOTHER FATHER TOTAL

A. INCOME COMPUTATION WAGE EARNER 1 Domestic Gross Income 2 Interstate Pay Adjustment B. INCOME COMPUTATION SELF-EMPLOYED 1 Self-Employment Gross Income* 2 Reasonable Business Expenses 3 Self Employment After Expenses C. ADJUSTMENTS TO DOMESTIC GROSS INCOME 1 2 3 4 5 6 7 Domestic Gross Income Other Court-Ordered Child Support Paid (-) Court-Ordered Maint Paid in this Case (-) Court-Ordered Maint Recd in this Case (+) Court Ordered Main. Paid in Other Case (-) Court-Ordered Main. Recd in Other Case (+) Child Support Income (Insert on Line D.1. below)

3000 0

4500 0

7500 7500

0 0 0

0 0 0

0 0

3000 0 0 300

4500 0 -300 0

7500

3300

4200

7500

D. COMPUTATION OF CHILD SUPPORT 1 Child Support Income 2 Proportionate Shares of Combined Income 3300 44.00 4200 56.00

(Percent)

Age of Children Number Per Age Category Amount Per Child Total Amount

0-5 0 0 0

6-11 1 1100 1100

12-18 0 0 0

Total 1 1100

3 Gross Child Support Obligation** * Interstate Pay Differential Adjustment? **Multiple Family Application? Number of Additional Children

1100 No No 0

Case No. 12CV1212 D. COMPUTATION OF CHILD SUPPORT 3 Gross Child Support Carried Over Page 1 4 Health and Dental Insurance Premium 5 Work-Related Child Care Costs (Tax Credit) 6 Parents' Total Child Support (Line D3 plus D4 and D5) 7 Parent Child Support Oblig. 8 Adjustment for Health/Work Related 9 Basic Parental Child Support Obligation E. CHILD SUPPORT ADJUSTMENTS 1 2 3 4 5 6 7 8 Long Distance Parenting Costs Parenting Time Adjustment Income Tax Cons: Exemption Income Tax Cons: Head of Household Special Needs Support Past Minority Overall Fin. Condition Total Adjustments MOTHER 0 0 0 0 0 0 0 0 FATHER 0 0 0 0 0 0 0 0 MOTHER FATHER TOTAL 1100 400 300 -60 1740

0 300 -60

400 0 0

766 -240 526

974 -400 574

1100

F. ADJUSTED CHILD SUPPORT SUMMARY 1 2 3 4 5 6 Basic Parental Child Support Section E Adjustments Adjustment Subtotal Parent Time Adjustment Enforcement Fee Net Parental Child Support Obligation MOTHER 526 0 526 0 0 0 FATHER 574 0 574 0 5 579

___________________________________ Judge/Hearing Officer s/ John Q. Smith 111 W. 1st Anywhere, KS 12121 12121212 12121212 12121212@1212.com Pro Se ___________________________________ Date Signed Phone Fax ___________________________________ Date Approved