|
+ Case: + Petitioner: + Respondent: |
+
+ Court Case No.: + Number of Children: + Calculation Date: |
+
| Income Component | +Petitioner | +Respondent | +
|---|---|---|
| Monthly Gross Income | +$ |
+ $ |
+
| Monthly Net Income (after allowable deductions) | +$ |
+ $ |
+
| COMBINED NET MONTHLY INCOME | +
+ $ |
+ |
| Combined Net Monthly Income (from Step 1) | +$ |
+
| Number of Children | +|
| Basic Support Obligation (from FL DCF Schedule) | +
+ $ |
+
| Adjustment | +Petitioner | +Respondent | +
|---|---|---|
| Health Insurance Premium (child's share) | +$ |
+ $ |
+
| Childcare Costs (work-related) | +$ |
+ $ |
+
| Extraordinary Expenses | +$ |
+ $0.00 | +
| Total Adjusted Support Obligation | +
+ $ |
+ |
| Petitioner Overnights/Year | +|
| Respondent Overnights/Year | +|
| Substantial Timesharing Applies (>73 overnights) | +
+ |
+
| + Formula: Each parent's obligation = Basic × (1 + other parent's %) × (their overnight%) × 1.5 + Net payment = difference between the two computed obligations + | +|
| Timesharing Credit Applied | +
+ $ |
+
| Petitioner's Monthly Obligation | +$ |
+
| Respondent's Monthly Obligation | +$ |
+
| NET MONTHLY PAYMENT ( |
+
+ $ |
+
|
+ In Re: The Matter of: + + Petitioner, + and + + Respondent. + |
+
+ Case No.: + Division: + Judge: |
+
|
+
+
+
+
+ |
+
+ Date: ______________________
+ |
+
|
+ + vs. + |
+
+ Case No.: |
+
|
+
+ CLERK OF THE CIRCUIT COURT
+ + Miami-Dade County, Florida + |
+
+ Date: ______________________
+ |
+
|
+ + vs. + |
+
+ Case No.: + Division: |
+
|
+
+
+ |
+
+ Date: ______________________
+ |
+
|
+ + vs. + |
+
+ Case No.: + Division: |
+
| Full Legal Name: | +Date of Birth: | +||
| Address: | +
+ |
+ ||
| Phone: | +Email: | +||
| Role in Case: | +[ ] Petitioner [ ] Respondent | +||
| Number of persons in household: | +|
| Monthly Gross Income (all sources): | +$ |
+
| Annual Gross Income (× 12): | +$ |
+
| Federal Poverty Level (200%) for household of |
+ $ |
+
|
+
+ Signature of Applicant
+
+ |
+
+ Date: ______________________
+ |
+
|
+ + vs. + |
+
+ Case No.: + Division: |
+
| Name: | +Date of Birth: | +||
| Address: | +
+ |
+ Phone: | +|
| Employer: | +Occupation: | +||
| Employment Type: | +
+ |
+ ||
| Income Source | +Monthly Amount | +Annual Amount | +
| Salary/Wages (gross, before deductions) | +$ |
+ $ |
+
| Bonuses / Commissions (average/12 if variable) | +$ |
+ $ |
+
| Business Income (net profit if self-employed) | +$ |
+ $ |
+
| Rental Income | +$ |
+ $ |
+
| Investment / Dividend / Interest Income | +$ |
+ $ |
+
| Social Security / Disability / VA Benefits | +$ |
+ $ |
+
| Pension / Retirement Income | +$ |
+ $ |
+
| Alimony Received (NOT from this case) | +$ |
+ $ |
+
| Other Income (specify): ________________________ | +$ |
+ $ |
+
| TOTAL MONTHLY GROSS INCOME | +
+ $ |
+
+ $ |
+
| Deduction | +Monthly Amount | +
| Federal Income Tax Withheld (use actual withholding) | +$ |
+
| Florida Income Tax (N/A — no FL income tax) | +$0.00 | +
| FICA — Social Security (6.2% of wages up to wage base) | +$ |
+
| FICA — Medicare (1.45% of wages, +0.9% above $200K) | +$ |
+
| Mandatory Union Dues | +$ |
+
| Mandatory Retirement (required by employer, not voluntary) | +$ |
+
| Child Support Paid (other cases only — court-ordered) | +$ |
+
| Alimony Paid (prior court orders only) | +$ |
+
| TOTAL MONTHLY DEDUCTIONS | +
+ $ |
+
| NET MONTHLY INCOME (Gross − Deductions) | +
+ $ |
+
| Expense | +Monthly Amount | +Notes | +
| Rent / Mortgage | $__________ | |
| Utilities (electric, gas, water) | $__________ | |
| Telephone / Cell Phone | $__________ | |
| Food / Groceries | $__________ | |
| Transportation (car payment, gas, insurance) | $__________ | |
| Health Insurance (self only — child's portion in Section VI) | $__________ | |
| Out-of-Pocket Medical / Dental | $__________ | |
| Entertainment / Dining Out | $__________ | |
| Clothing | $__________ | |
| Travel / Vacation | $__________ | |
| Other (specify): ________________________ | $__________ | |
| TOTAL MONTHLY EXPENSES | +$__________ | ++ |
| Asset Description | +Current Value | +Marital/Non-Marital | +
| Real Property (homestead): ________________________ | $__________ | [ ] M [ ] NM |
| Real Property (other): ________________________ | $__________ | [ ] M [ ] NM |
| Checking / Savings Accounts | $__________ | [ ] M [ ] NM |
| Investments / Brokerage Accounts | $__________ | [ ] M [ ] NM |
| Retirement / 401(k) / IRA / Pension | $__________ | [ ] M [ ] NM |
| Vehicle(s): ________________________ | $__________ | [ ] M [ ] NM |
| Business Interest / Ownership | $__________ | [ ] M [ ] NM |
| Other Assets: ________________________ | $__________ | [ ] M [ ] NM |
| TOTAL ASSETS | +$__________ | ++ |
| Creditor / Liability | +Monthly Payment | +Balance Owed | +Marital/Non-Marital | +
| Mortgage: ________________________ | $__________ | $__________ | [ ] M [ ] NM |
| Auto Loan: ________________________ | $__________ | $__________ | [ ] M [ ] NM |
| Credit Cards: ________________________ | $__________ | $__________ | [ ] M [ ] NM |
| Student Loans | $__________ | $__________ | [ ] M [ ] NM |
| Other: ________________________ | $__________ | $__________ | [ ] M [ ] NM |
| TOTAL LIABILITIES | +$__________ | +$__________ | ++ |
| Health Insurance Premium (child's share only) | +$ |
+
| Work-Related Childcare Cost | +$ |
+
| Extraordinary Expenses (medical, educational) | +$__________/month | +
|
+
+ Signature of Affiant
+
+ |
+
+ Date: ______________________
+ |
+
|
+
+ Notary Public — State of Florida
+
+
+ My Commission Expires: ____________________
+
+ |
+
+ [ ] Personally Known + [ ] Produced ID: ____________________ + |
+
|
+ IN RE: THE MARRIAGE OF: + |
+
+ Case No.: + Division: |
+
| AND + |
+
| Occupation/Employer: | +|
| Employer Address: | +|
| Employer Phone: | +|
| Employment Type: | +
| Gross Monthly Income (all sources) | +
+ $ |
+
|
+ + |
+ $ |
+
| Federal Income Tax Withholding | +$ |
+
| Social Security (6.2%) | +$ |
+
| Medicare (1.45%) | +$ |
+
| Mandatory Retirement Contributions | +$ |
+
| Union Dues | +$ |
+
| NET MONTHLY INCOME (FL 61.30) | +
+ $ |
+
|
+
+ Signature of
+
+ Printed Name:
+
+ Date: ______________________
+
+ |
+
+ SWORN TO or AFFIRMED before me this + _______ day of _______________, 20_____ +
+ Notary Public — State of Florida
+
+
+ My Commission Expires: _______________
+
+ |
+
| Employer Name: | +|
| Employer Address: | +
+ |
+
| Employer Phone: | +|
| Employer FEIN: | +
| Name: | +|
| Address: | +
+ |
+
| SSN (Last 4): | +XXX-XX- |
+
| Date of Birth: | +
| Monthly Child Support | +
+ $ |
+
| Monthly Arrears Payment | +$ |
+
| TOTAL MONTHLY WITHHOLDING | +
+ $ |
+
|
+ In Re: The Matter of: + + Petitioner, + and + + Respondent. + |
+
+ Case No.: + Division: + Judge: |
+
| ✓ | +Document | +Date Provided | +
| + TAX RETURNS & INCOME DOCUMENTS + | +||
| [ ] | +Federal income tax returns — most recent 3 years (all schedules) | +____________________ | +
| [ ] | +All W-2 forms — most recent 3 years | +____________________ | +
| [ ] | +All 1099 forms — most recent 3 years (if applicable) | +____________________ | +
| + CURRENT INCOME VERIFICATION + | +||
| [ ] | +Pay stubs — most recent 3 months (or last available) | +____________________ | +
| [ ] | +Proof of income from all other sources (SS, disability, alimony, rental, etc.) | +____________________ | +
| + SELF-EMPLOYMENT / BUSINESS (if applicable) + | +||
| [ ] | +Business tax returns — most recent 3 years (all schedules) | +____________________ | +
| [ ] | +Profit & Loss statements — most recent 12 months | +____________________ | +
| [ ] | +Corporate/partnership K-1 forms (if applicable) | +____________________ | +
| + BANK & FINANCIAL ACCOUNTS + | +||
| [ ] | +Bank statements — all accounts — most recent 3 months | +____________________ | +
| [ ] | +Investment / brokerage statements — most recent quarter | +____________________ | +
| [ ] | +Retirement account statements (401k, IRA, pension) — most recent | +____________________ | +
| + FINANCIAL AFFIDAVIT (REQUIRED) + | +||
| [ ] | ++ Financial Affidavit (FL-12.902(b) Short Form — income < $50,000/yr, + OR FL-12.902(c) Long Form — income ≥ $50,000/yr) — signed and notarized + | +____________________ | +
| + CHILD-RELATED EXPENSES (if children involved) + | +||
| [ ] | +Health insurance cost documentation (monthly premium for child) | +____________________ | +
| [ ] | +Childcare cost documentation (monthly work-related expense) | +____________________ | +
| + REAL PROPERTY (if applicable) + | +||
| [ ] | +Mortgage statements — all real property — most recent | +____________________ | +
| [ ] | +Property tax notices (most recent year) | +____________________ | +
|
+
+
+ |
+
+ Date: ______________________
+ |
+
|
+ + vs. + |
+
+ Case No.: + Division: |
+
|
+ In Re: The Matter of: + + Petitioner, + and + + Respondent. + |
+
+ Case No.: + Division: + Judge: |
+
|
+ + vs. + |
+
+ Case No.: + Division: |
+
| Deponent: | +|
| Deponent Type: | +|
| Date & Time: | +|
| Location: | +|
| Court Reporter: | +|
| Max Duration: | +Up to |
+
|
+ + vs. + |
+
+ Case No.: + Division: |
+
| Child's Full Name | +Date of Birth | +Social Security Number | +
| _____ - _____ - _____ | +
| Child's Full Name | +Date of Birth | +Social Security Number | +
| ________________________ | ____________ | _____ - _____ - _____ |
| ________________________ | ____________ | _____ - _____ - _____ |
| ________________________ | ____________ | _____ - _____ - _____ |
|
+
+
+ |
+
+ Date: ______________________
+ |
+
|
+ In Re: The Matter of: + + Petitioner, + and + + Respondent. + |
+
+ Case No.: + Division: + Judge: |
+
| Parent A (Petitioner): | +Address: | +
+ |
+ |
| Parent B (Respondent): | +Address: | +
+ |
+
| Child's Full Name | +Date of Birth | +Age | +School | +
| Child's Full Name | +Date of Birth | +Age | +School | +
| ________________________ | ____________ | ___ | ________________________ |
| ________________________ | ____________ | ___ | ________________________ |
| Parent A (Petitioner) Overnights/Year: | +|
| Parent B (Respondent) Overnights/Year: | +|
| + ✓ Substantial timesharing applies (Parent B >73 overnights) — FL 61.30(11)(b) formula used for support + | +|
| New Year's Day: | [ ] A [ ] B [ ] Alt | +Spring Break: | [ ] A [ ] B [ ] Alt | +
| Memorial Day: | [ ] A [ ] B [ ] Alt | +Independence Day: | [ ] A [ ] B [ ] Alt | +
| Labor Day: | [ ] A [ ] B [ ] Alt | +Thanksgiving: | [ ] A [ ] B [ ] Alt | +
| Winter Break (1st half): | [ ] A [ ] B [ ] Alt | +Winter Break (2nd half): | [ ] A [ ] B [ ] Alt | +
| Mother's Day: | [ ] A [ ] B [ ] Mother | +Father's Day: | [ ] A [ ] B [ ] Father | +
|
+
+
+ + Parent A / Petitioner + Date: ______________________
+ |
+ + |
+
+
+ + Parent B / Respondent + Date: ______________________
+ |
+