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

 

 

(Utah Bar #:__________) 

 

(Utah Bar #:__________) 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

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) 

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

Child Support Obligation Worksheet 
– Sole Physical Custody  
(Utah Code 78B-12-301 and 302) 

_______________________________ 
Case Number 

_______________________________ 
Judge 

_______________________________ 
Commissioner (domestic cases) 

Write the names of the parents: 

_____________ 
(name:  
PARENT 1) 

_____________ 
(name:  
PARENT 2) 

COMBINED 

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

parents for whom support is to be awarded. 

 

 

 

1021FAJ Approved November 25, 
2019 / Revised May 1, 2022 

Child Support Obligation Worksheet  

– Sole Physical Custody and Paternity 

Page 1 of 3 

and  

 

 

 

 

 

 

 

 

 

$ 

$ 

%   

2a. Enter the parents’ 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 Line 1.) 

2d. OPTIONAL: Enter the amount from Line 12 of the 

Children in Present Home Worksheet for either parent. 

3.  Subtract Lines 2b, 2c, and 2d 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 Base 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.  BASE CHILD SUPPORT AWARD: Bring down the 

amount(s) from Line 6 or enter the amount(s) from the 
Low Income table per U.C.A. 78B-12-205. The 
parent(s) without physical custody of the child(ren) 
pay(s) the amount(s) all 12 months of the year. 

$ 

- 

- 

- 

$ 

$ 

$ 

8. 

Who must pay child support? 

$ 

- 

- 

- 

$ 

$ 

$ 

 

% 

[  ]  Parent 1 
[  ]  Parent 2 
[  ]  Both 

[  ]  Yes    [  ] No  

9. 

Is the support award the same as the guideline amount in Line 10?   

If YES, you are done with this section. Complete the Certificate of Service. 

If NO, enter the amount ordered:  

[  ]  Parent 1  $_______________ 
[  ]  Parent 2  $_______________ 

10.  What were the reasons stated by the court for the deviation?  

[  ] 
[  ]  
[  ] 
[  ] 

property settlement 
excessive debts of the marriage 
absence of need of the parent to receive child support 
other: ______________________________________ 

1021FAJ Approved November 25, 
2019 / Revised May 1, 2022 

Child Support Obligation Worksheet  

– Sole Physical Custody and Paternity 

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 

 

 

1021FAJ Approved November 25, 
2019 / Revised May 1, 2022 

 

Child Support Obligation Worksheet  

– Sole Physical Custody and Paternity 

Page 3 of 3 

 

INSTRUCTIONS FOR THE SOLE PHYSICAL CUSTODY WORKSHEET 

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

Line 1.   Enter the number of natural and adopted children of the parents for whom 
support is to be determined. Do not include any children of either parent by 
another partner on this line. If a child for whom support is to be determined is 
an unemancipated minor who does not live with his parents, use the total 
number of children, including the unemancipated minor, by that set of parents 
for Line 1. 

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. 

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.  Enter the amount of alimony either 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. Canceled checks 
or a statement from the recipient of the alimony may be accepted as 
verification. 

1021FAJ Approved November 25, 2019 / Revised 
November 22, 2021 

Child Support Obligation Worksheet  

– Sole Physical Custody and Paternity 

 

 

 

 

 

Line 2c.  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. 

Line 2d.  U.C.A. 78B-12-210(6) states: “(a) Natural or adoptive children of either parent 

who live in the home of that parent and are not children in common to both 
parties may at the option of either party be taken into account under the 
guidelines in setting a child support award, as provided in Subsection (7); (b) 
Additional worksheets shall be prepared that compute the base child support 
award of the respective parents for the additional children. The base child 
support award shall then be subtracted from the appropriate parent's income 
before determining the award in the instant case. 

U.C.A. 78B-12-210 (7) states: “In a proceeding to adjust or modify an existing 
award, consideration of natural or adoptive children born after entry of the 
order and who are not in common to both parties may be applied to mitigate 
an increase in the award but may not be applied: (a) for the benefit of the 
obligee [the parent who receives child support] if the credit would increase the 
support obligation of the obligor [the parent who must pay child support] from 
the most recent order; or (b) for the benefit of the obligor [parent who must pay 
child support] if the amount of support received by the obligee [the parent who 
receives child support] would be decreased from the most recent order.” 

Line 3.   (See U.C.A. 78B-12-205) If the parent who must pay child support’s income is 

over $1,050 complete the calculation as directed. If the parent who must pay 
child support’s income is $650 to $1,050 then calculate the child support 
award using the "Combined Child Support Obligation Table" and the "Low 
Income Table." The child support award will be the lesser of the two amounts. 
Enter the lesser of the two amounts on Line 7. If the parent who must pay child 
support’s income is $649 or less, the court may determine the child support 
amount, but the amount may not be less than $30; refer to U.C.A. 78B-12-
205(6). 

Line 4.   The amount on the "Combined Child Support Obligation Table" (U.C.A. 78B-

12-301) shows the amount BOTH parents combined should contribute for the 
support of their children. 

Line 5.   Calculate each parent's share of the amount in Line 4 as a percentage figure. 

Line 6.   Calculate each parent's share of the amount in Line 4 as a dollar amount. 

Line 7.   The Base Child Support Award is the amount the parent who must pay child 

support pays to the parent who receives child support. This is the amount the 

1021FAJ Approved November 25, 2019 / Revised 
November 22, 2021 

Child Support Obligation Worksheet  

– Sole Physical Custody and Paternity 

 

 

 

 

parent(s) without physical custody of the child(ren) pays all 12 months of the 
year.  

Line 8.   Designate which parent or parents have a support obligation based on this 

worksheet. 

amount in Line 7. 

Line 9.   Complete Line 9 to indicate if the amount ordered deviates from the guideline 

Line 10.  Complete Line 10 if the parent who must pay child support will not be ordered 
to pay the guideline amount from either the "Combined Child Support 
Obligation Table," "Low Income Table" or in accordance with U.C.A. 78B-12-
205. 

1021FAJ Approved November 25, 2019 / Revised 
November 22, 2021 

Child Support Obligation Worksheet  

– Sole Physical Custody and Paternity