| Noncustodial Parent |
Custodial Parent |
Yearly wage
income |
|
|
Yearly
self-employment income |
|
|
Yearly
alimony income |
|
|
Yearly unearned
taxable income |
|
|
|
|
|
Description
|
Noncustodial Parent |
Custodial Parent |
Federal
Tax
|
State
Tax
|
FICA
|
Pension?
|
|
|
N/A
|
|
|
|
|
|
|
N/A
|
|
|
|
|
|
N/A
|
|
|
|
|
|
|
N/A
|
|
|
|
|
|
|
|
|
|
Noncustodial Parent
|
Custodial Parent
|
|
|
|
|
Noncustodial Parent |
Custodial Parent |
Number of
children as tax dependents |
|
|
Over age 65? |
|
|
Blind? |
|
|
Tax Filing Status |
|
|
Federal Tax
Credits
Description |
|
|
|
|
N/A
|
|
N/A
|
|
State Tax
Credits
Description |
|
|
|
|
N/A
|
|
N/A
|
|
Number of
Dependents Age 17 and Older
|
|
|
School District Surtax (see below)
|
|
|
|
|
|
|
Noncustodial Parent |
Custodial Parent |
Yearly Union
Dues |
|
|
Yearly Mandatory
Occupational License Fees |
|
|
Yearly Medical
Insurance (child's portion
only) |
|
|
Check if insurance provided at no cost:
|
|
|
Yearly Child
Support (prior order) |
|
|
Yearly Spousal
Support (prior order) |
|
|
Yearly Medical
Support (prior order) |
|
|
Yearly Child
Care Expenses |
|
|
Number of kids in childcare |
|
|