City, State, Zip 

 
Name 

 
Address 

 
Phone 

 
Email 

 

 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address. 
 

I am   [  ]  Petitioner 

[  ]  Respondent 
[  ]  Respondent’s Attorney                     (Utah Bar #:__________) 

[  ]  Petitioner’s Attorney 
[  ]  Petitioner’s Licensed Paralegal Practitioner 
[  ]  Intervenor  
[  ]  Intervenor’s Attorney  

 

 

 

(Utah Bar #:__________) 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

Child Support Obligation Worksheet 
– Other Children Present in the 
Parent’s Home 
(Utah Code 78B-12-301 and 302) 

_______________________________ 
Case Number 

_______________________________ 
Judge 

_______________________________ 
Commissioner (domestic cases) 

In the Matter of (select one) 
 

[  ]  the Marriage of (for a divorce with or without 
children, annulment, separate maintenance, or 
temporary separation case) 
[  ]  the Children of (to establish custody, parent-
time or child support) 
[  ]  the Parentage of the Children of (for a 
paternity case) 

____________________________________ 
(name of Petitioner) 

and  

 

____________________________________ 
(name of Respondent) 
____________________________________________ 
Other parties (if any) 

Write the names of the parents: 

_____________ 
(name:  
PARENT IN 
THIS ACTION) 

_____________ 
(name:  
OTHER 
PARENT) 

COMBINED 

1.  Enter the # of natural and adopted children of these 

parents. 

 

 

 

1023FAJ Approved November 25, 
2019 / Revised May 1, 2022 
 

Child Support Obligation Worksheet – Other Children 
Present in the Parent’s Home 

Page 1 of 3 

 

 

 

 

$ 

  $ 

%  

 

$ 

 $ 

2a. Enter the parent’s gross monthly income. Refer to 

Instructions for definition of income. 

2b. Enter previously ordered alimony that is actually paid. 

(Do not enter alimony ordered for this case.) 

2c. Enter previously ordered child support. (Do not enter 
obligations ordered for the children in this case.) 

3.  Subtract Lines 2b and 2c from 2a. This is the Adjusted 

Gross Income for child support purposes. 

4.  Take the COMBINED figure in Line 3 and the number of 
children in Line 1 to the Support Table (U.C.A. 78B-12-
301). Find the Combined Support Obligation. Enter it 
here. 

5.  Divide each parent's adjusted monthly gross in Line 3 by 

the COMBINED adjusted monthly gross in Line 3. 

6.  Multiply Line 4 by Line 5 for each parent to obtain each 

parent's share of the Base Support Obligation. 

7.  Enter the amount of the children’s portion of the 

insurance premium actually paid. 

8.  Enter the monthly work or training related child care 

expense for the children in Line 1.  

$ 

- 

- 

$ 

$ 

 

 

$ 

- 

- 

$ 

 

% 

$ 

 

 

PARENT’S SHARE OF BASE CHILD SUPPORT AWARD 
FOR THE CHILDREN IN LINE1.  
Enter the amount for the parent in this action from Line 6. 

PARENT’S SHARE OF CHILDREN'S INSURANCE FOR THE 
CHILDREN IN LINE 1.  
Multiply Line 7 by .50, and enter the result here. 

PARENT’S SHARE OF WORK OR TRAINING RELATED 
CHILD CARE EXPENSES FOR THE CHILDREN IN LINE 1. 
Multiply Line 8 by .50, and enter the result here. 

PARENT’S SHARE OF TOTAL CHILD SUPPORT 
OBLIGATION TO THE CHILDREN IN LINE 1.  
Add Lines 9,10, and 11. This amount may be used to adjust 
the parent in this action’s gross income on the sole, split, or 
joint custody worksheets. 

$ 

$ 

$ 

$ 

. 

  9

10. 

11. 

12. 

1023FAJ Approved November 25, 
2019 / Revised May 1, 2022 
 

Child Support Obligation Worksheet – Other Children 
Present in the Parent’s Home 

Page 2 of 3 

 

 

 

 

Certificate of Service 

I certify that I filed with the court and am serving a copy of this Child Support Obligation Worksheet on the 
following people. 

Person’s Name 

Service Method 

Service Address 

Service 
Date 

 

 

 

 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

 

 

 

 
Date 

Signature ► 

Printed Name 

 

 

1023FAJ Approved November 25, 
2019 / Revised May 1, 2022 
 

Child Support Obligation Worksheet – Other Children 
Present in the Parent’s Home 

Page 3 of 3 

 

Instructions for the Child Support Obligation Worksheet  
– Other Children Present in the Parent’s Home 

See Office of Recovery Services Child Support Calculator for assistance in filling out 
this form.  

Use this worksheet to determine the parent’s obligation for natural or adopted children 
who live in the parent’s home and who are not children of the other parent listed on the 
Sole, Split, or Joint Custody Worksheets (primary worksheets). The parent may use this 
worksheet in modifying an existing child support award, setting a paternity award, or 
other appropriate circumstances where the parent has child support obligations for other 
children. 

OTHER PARENT name: The other parent may be a current spouse, partner, or an ex-
spouse of the parent.  

Line 1.   Enter the number of natural or adopted children of the parent in this action and 

the other parent named on this worksheet. If the parent in this action has 
children in their home by more than one other parent, complete a separate 
Child Support Obligation Worksheet – Other Children Present in the Parent’s 
Home for the children of each other parent. 

Line 2a.  Enter each parent’s gross monthly income. U.C.A. 78B-12-203(1) states: “As 
used in the guidelines, ‘gross income’ includes prospective income from any 
source, including earned and nonearned income sources which may include 
salaries, wages, commissions, royalties, bonuses, rents, gifts from anyone, 
prizes, dividends, severance pay, pensions, interest, trust income, alimony 
from previous marriages, annuities, capital gains, Social Security benefits, 
workers' compensation benefits, unemployment compensation, income 
replacement disability insurance benefits, and payments from ‘nonmeans-
tested’ government programs.”  

 

 

U.C.A. 78B-12-203(2) states: “Income from earned income sources is limited 
to the equivalent of one full-time 40-hour job.” Refer to U.C.A. 78B-12-203 for 
additional information about determining gross income. 

U.C.A. 78B-12-203(3) says:  “specifically excluded from gross income are: 
(a)  cash assistance provided under Title 35A, Chapter 3, Part 3, Family 
Employment Program; 
(b)  benefits received under a housing subsidy program, the Job Training 
Partnership Act, Supplemental Security Income, Social Security Disability 
Insurance, Medicaid, SNAP benefits, or General Assistance; and 
(c)  other similar means-tested welfare benefits received by a parent. 

1023FAJ Approved November 25, 2019 / Revised 
November 22, 2021 
 

Child Support Obligation Worksheet – Other Children Present in the Parent’s 
Home 

 

 

 

 

 

All income must be verified. Verification includes: year to date pay stubs, 
employer statements or records, the last year's tax return and documentation 
of non-earned income appropriate to the source. 

Line 2b.  In the Parent in this Action column, enter the amount of alimony the parent is 

court ordered to pay and actually pays to a former spouse [U.C.A. 78B-12-
204(1)]. Do not include alimony payments for this case. Alimony payments 
must be verified. Cancelled checks or a statement from the recipient of the 
alimony may be accepted as verification. 

In the Other Parent column enter the monthly alimony that the parent is paying 
to someone other than the parent listed in the worksheet.  

Line 2c.  In the Parent in this Action column, enter the amount of any child support 

orders either parent is ordered to pay for children by another partner [(U.C.A. 
78B-12-204(1)].  

A copy of the order is required for verification. 

In the Other Parent column list the amount that the other parent is ordered to 
pay for children other than those listed on this worksheet.  

Line 7.  

In the combined column, enter the children's portion of insurance premium that 
is actually paid. To determine the children's portion divide the total premium by 
the number of persons covered by the policy and then multiply that number by 
the number of children listed on this worksheet that are covered by policy. 

Line 8.   Enter the amount of work-related, reasonable, child care expenses for up to a 

full-time work week or training schedule.  

Line 9.   Complete this line as directed.  

Line 10.  Complete the calculation as directed.  

Line 11.  Complete the calculation as directed.  

Line 12.   Enter the amount on this line on Line 2d of the Sole Custody Worksheet, Line 
3d of The Split Custody Worksheet or Line 2d of the Joint Custody Worksheet.  

1023FAJ Approved November 25, 2019 / Revised 
November 22, 2021 
 

Child Support Obligation Worksheet – Other Children Present in the Parent’s 
Home