29/30/2001 10:37 785-233-7061 \ DAVID MILLER OR LMR PAGE 10 IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS Division Inthe Matar ofthe Marrogs of HAL RICHARDSON ase No se0217 and Ohision 2 CLAUDINE DOMBROWSK! ‘CHILD SUPPORT WORKSHEET {SUBMITTED BY MOTHER) MOTHER FATHER TOTAL ‘GROSS ANNUAL INCOMES tose 292837320 [A INCOME COMPUTATION - WAGE EARNER 4. Domestic Gross neame (Wages, ner, et.) oot 220 3m 6, INCOME COMPUTATION - SELF-EMPLOYED 4. SelHEmplayment Gross Income ° ° 2. Reasonable Business Expenses (iil SE tx) ° ° 2. Domestic Groes Income (Sai-Emploved) TT ° (¢, ADVUSTMENTS TO DOMESTIC GROSS INCOME + Gross income (TetakMonity) oo 2210 Coat of Living Adjustment ° ° 2. Other Cour-Ordored Child Suppor Paid ° ° 3 Maintenance Recs (Paid) in this case ° ° 4 Maintenance Rect (Paid) ther cases ° ° 5. Chid Support Income aa D. COMPUTATION OF CHILD SUPPORT +. Che Suppor income oot 220 3110 2 Proporvenate Share of Combined neame 288% Tham 100% 3. Basic Child Support Obigation ‘ge of citron cope] Number per age 7 ° ° “Amount per child a8 ° ° eg eo Tors 376 o 3 a803/30/2801 10: 785-233-7061 Page? 1. COMPUTATION OF CHILD SUPPORT (Cont) 4 Health and Dentp!Ingurance Premium ‘5, Work-Related Child Care Coste Less Chi Gare Tax Gredit incl Kansas cred) 6, Parente’ Total Chia Support Obigation 7, Each Parents Child Support Obigation 1. Adjustment for Insurance & Chkd Gara 9, Net Parental Child Suppor Obigation (Percentage of Parents Gross jncothe} E CHILD SUPPORT ADJUSTMENTS Applicable Category Yes No. 1 %] Long Dist. Vistation Coxts 2 XE] Vietation Adjustrient 3. Income Tax Considerations 4 Special Needs 5, ‘Agreement Past Minority 8 57] Ovarall Financial Condition 7 Total Adjustments: F ADJUSTED CHILD SUPPORT SUMMARY (Deviations trom rebuttable presumption amount) 4. Beale Parental Child Support Obligation 2 Total Chitd Support Adjustments 2. Agjusted Subtotal ‘Child Support Payable by Mother Child Support Enforcement Pee Atlowance: Total Amount Payable Prepared by Leonard M. Robinson # PO Box 8138 Topeka, KS 68608-0138 785 233-7001 ‘Atorey for Respondent ‘Administrative Order No. 128 DAVID MILLER OR LY PAGE 11 Caae No, 9640-217 MOTHER FATHER TOTAL ° a e ° as 0 3 a) 3 i BF a6 220 sor ° wen) Be 7 ve 260% 260% (Arnount Allowed] fier | Fate 3 5 ° 9 e 2 ° ° 0 0 9 0 a za Q MOTHER FATHER 230 126 2) 26 wi we 2s i a Sloe Date 2-30 -0f Prepares aos 2 vanion 124 Conga ray Sore