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STATE OF RHODE ISLAND

FC-78 (revised June 2020) STATE OF RHODE ISLAND FAMILY COURT CHILD SUPPORT GUIDELINE WORKSHEET Plaintiff Civil Action File Number Defendant To be filed with complaints for divorce, for divorce on bed and board, miscellaneous complaints, and when an answer or modification is filed. Number of children: _____ Plaintiff Defendant Combined 1. Monthly Gross Income$_____ $_____ XXX 2. Required Deductions:-_____ -_____ a. Preexisting Child Support Payments-_____ -_____ XXX b. Health Insurance Premiums orMedical Cash Contributions-_____ -_____ XXX c.

combined income to child support table) XXX XXX _____ 7. Work-Related Child Care Costs (actual costs. minus federal tax credit) XXX XXX _____ 8. Total Child Support Obligation (add lines 6 and 7) XXX XXX $_____ 9. Parent's Child Support Obligation (for each

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1 FC-78 (revised June 2020) STATE OF RHODE ISLAND FAMILY COURT CHILD SUPPORT GUIDELINE WORKSHEET Plaintiff Civil Action File Number Defendant To be filed with complaints for divorce, for divorce on bed and board, miscellaneous complaints, and when an answer or modification is filed. Number of children: _____ Plaintiff Defendant Combined 1. Monthly Gross Income$_____ $_____ XXX 2. Required Deductions:-_____ -_____ a. Preexisting Child Support Payments-_____ -_____ XXX b. Health Insurance Premiums orMedical Cash Contributions-_____ -_____ XXX c.

2 Additional Minor Dependents-_____ -_____ XXX d. Work Related Child Care Cost Share -_____ -_____ XXX 3. Optional Adjustments in the Discretion of the Courta. Pension/Retirement Payments-_____ -_____ XXX b. Life Insurance Premium Payments-_____ -_____ XXX c. Parent's Extraordinary Medical Expenses-_____ -_____ XXX d. Income Tax Exemptions Adjustment +/-_____ +/-_____ XXX e. Payments of Assigned Marital Debts-_____ -_____ XXX 4. Monthly Adjusted Gross Income (line 1minus lines 2 and 3)$_____ $_____ $_____ 5. Percentage Share of Income (line 4 parents income divided by line 4 combined income) _____ _____ 100% 6.

3 Basic Child Support Obligation (apply line 4combined income to child support table) xxx xxx _____ 7. Work-Related Child Care Costs (actual costsminus federal tax credit) xxx xxx _____ 8. Total Child Support Obligation(add lines 6 and 7) xxx xxx $_____ 9. Parent's Child Support Obligation (for eachparent, line 5 percentage X line 8)$_____ $_____ XXX 10. Recommended Child Support Order (enterline 9 amount for non-custodial parent only;leave other column blank)$_____ $_____ XXX 11. Basic Child Support Amount Ordered:$_____ per _____ weekly/bi-weekly/monthly 12.

4 Cash Medical Ordered:$_____ per _____ weekly/bi-weekly/monthly 13. TOTAL AMOUNT ORDERED:$_____ per _____ (add lines 11 and 12)weekly/bi-weekly/monthly Prepared and presented By/for the plaintiff _____ Date _____ By/for the defendant _____ Date _____ Prepared and presented by the Office of Child Support Services (if applicable): _____ Date: _____ Entered as an Order of the court on _____. APPROVED: /s/ _____ Judicial Officer

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