CHILD SUPPORT QUESTIONNAIRE

Your answers to the following questions are completely CONFIDENTIAL and are covered by ATTORNEY-CLIENT PRIVILEGE. This information will not be shared with anyone other than those working on your case. Your response to these questions now will help organize your case and save litigation expenses in trying gather and assemble information after the case is in progress.

Please fill out this questionnaire completely and honestly and return it to our office as soon as possible. It is imperative that you are open and honest with your answers so that we may serve you to the best of our abilities. You should answer all questons relevant to your case. If a question does not apply to you, please mark the question "N/A".

In addition, please be sure to provide us with the documents listed in the "Checklist of Documents for Child Support."

Your Name*

First NameLast Name

Your Email*

example@example.com

Your ANNUAL GROSS income (before any taxes are taken out), including bonuses, second jobs, overtime pay, commissions, rental income, interest, dividends, etc. Please count all income from all sources and break down your annual income into components according to the below categories. In addition, please add categories under "other" if not included in this list.

Wages/Salary: blanks
Bonuses: blank
Commissions:
Interest:
Dividends:
Investments:
Rental Income:
Business Income:
Social Security:
Pension/Retirement:
Other:
Other:
Total Annual Gross Income:

Your MONTHLY GROSS income (before any taxes are taken out), including bonuses, second jobs, overtime pay, commissions, rental income, interest, dividends, etc. Please count all income from all sources and break down your monthly income into components according to the below categories. In addition, please add categories under "other" if not included in this list.

Wages/Salary: blanks
Bonuses: blank
Commissions:
Interest:
Dividends:
Investments:
Rental Income:
Business Income:
Social Security:
Pension/Retirement:
Other:
Other:
Total Monthly Gross Income:

Your MONTHLY NET income (after any taxes are taken out), including bonuses, second jobs, overtime pay, commissions, rental income, interest, dividends, etc. Please count all income from all sources and break down your monthly income into components according to the below categories. In addition, please add categories under "other" if not included in this list.

Wages/Salary: blanks
Bonuses: blank
Commissions:
Interest:
Dividends:
Investments:
Rental Income:
Business Income:
Social Security:
Pension/Retirement:
Other:
Other:
Total Monthly Net Income:

How often are you paid? (Choose only one of the options below.)

Once a monthBi-Monthly (24 paychecks per year)Every two weeks (26 paychecks per year)Other

If you selected "Other" in the above question, describe how often you get paid. Include whether your pay is periodic and if taxes or other deductions are taken out of your pay.

Please list the following deductions from your paycheck each pay period (to get from "gross" to "net"):

Federal Income Taxes: blanks
State Income Taxes: blank
Social Security (FICA):
Medicare:
Medical Insurance:
Life Insurance:
Retirement Plan:
Other:
Other:
Total Deductions:

Other parent's ANNUAL GROSS income (before any taxes are taken out), including bonuses, second jobs, overtime pay, commissions, rental income, interest, dividends, etc. Please count all income from all sources and break down the other parent's annual income into components according to the below categories. In addition, please add categories under "other" if not included in this list.

Wages/Salary: blanks
Bonuses: blank
Commissions:
Interest:
Dividends:
Investments:
Rental Income:
Business Income:
Social Security:
Pension/Retirement:
Other:
Other:
Total Annual Gross Income:

Other parent's MONTHLY GROSS income (before any taxes are taken out), including bonuses, second jobs, overtime pay, commissions, rental income, interest, dividends, etc. Please count all income from all sources and break down the other parent's monthly income into components according to the below categories. In addition, please add categories under "other" if not included in this list.

Wages/Salary: blanks
Bonuses: blank
Commissions:
Interest:
Dividends:
Investments:
Rental Income:
Business Income:
Social Security:
Pension/Retirement:
Other:
Other:
Total Monthly Gross Income:

Other parent's MONTHLY NET income (after any taxes are taken out), including bonuses, second jobs, overtime pay, commissions, rental income, interest, dividends, etc. Please count all income from all sources and break down the other parent's monthly income into components according to the below categories. In addition, please add categories under "other" if not included in this list.

Wages/Salary: blanks
Bonuses: blank
Commissions:
Interest:
Dividends:
Investments:
Rental Income:
Business Income:
Social Security:
Pension/Retirement:
Other:
Other:
Total Monthly Net Income:

How often is the other parent paid? (Choose only one of the options below.)

Once a monthBi-Monthly (24 paychecks per year)Every two weeks (26 paychecks per year)Other

If you selected "Other" in the above question, describe how often the other parent is paid. Include whether the other parent's pay is periodic and if taxes or other deductions are taken out of his/her pay.

Please list the following deductions from the other parent's paycheck each pay period (to get from "gross" to "net"):

Federal Income Taxes: blanks
State Income Taxes: blank
Social Security (FICA):
Medicare:
Medical Insurance:
Life Insurance:
Retirement Plan:
Other:
Other:
Total Deductions:

Who maintains health insurance (i.e. medical, dental, and/or vision) for the child(ren)?

What is the name of the health insurance carrier?

What is the total monthly premium payment? (for all persons covered on the policy)

Who pays the monthly premium payments?

How many adults are covered under this health insurance policy?

How many children are covered under this health insurance policy?

Are any of the children covered under this health insurance policy children of another marriage or relationship and NOT related to this child support matter? If yes, please specify.

On average, what are the child(ren)'s monthly unreimbursed/uninsured medical expenses? (i.e. expenses not covered by the health insurance policy)

Do the children attend daycare and/or before & after school care during the school year?

If yes, what are the daycare and/or before & after school care arrangements for each child during the school year?

How much do you pay for daycare and/or before & after school care per month for each child during the school year?

How much does the other parent pay for daycare and/or before & after school care per month for each child during the school year?

Do the children attend daycare during the summer months?

If yes, what are the daycare arrangements for each child during the summer months?

How much do you pay for daycare per month during the summer months?

How much does the other parent pay for daycare per month during the summer months?

Did you child(ren) attend any summer camp(s) during one or both of the past two summers? blanks

If yes, please answer the following:
How much did you pay total for summer camps for the child(ren) this past summer? blank

Please break down the costs and provide the following details for each camp:
1). Camp Name:
Child(ren) who attended:
Dates Attended:
Expense for the Camp:
Amount each parent paid:

2). Camp Name:
Child(ren) who attended:
Dates Attended:
Expense for the Camp:
Amount each parent paid:

3). Camp Name:
Child(ren) who attended:
Dates Attended:
Expense for the Camp:
Amount each parent paid:

4). Camp Name:
Child(ren) who attended:
Dates Attended:
Expense for the Camp:
Amount each parent paid:

How much do you pay for work-related childcare for all children for the entire year?

How much does the other parent pay for work-related childcare for all children for the entire year?

How would you like to see child care arrangements changed in the future, if at all?

How would you like the child care payments to be made in the future?

Are you required (i.e. court-ordered, agreement-required) to pay child support for any child(ren) living with you that is not subject to this child support matter? If so, please specify.

Is the other parent required (i.e. court-ordered, agreement-required) to pay child support for any child(ren) living with him/her that is not subject to this child support matter? If so, please specify.

Do you pay any extraordinary expenses for the child(ren)? (i.e. expenses related to special or private schooling to meet a child's particular education needs, significant travel expenses for transporting child, or therapy/counseling). If so, please specify.

Does the other parent pay any extraordinary expenses for the child(ren)? (i.e. expenses related to special or private schooling to meet a child's particular education needs, significant travel expenses for transporting child, or therapy/counseling). If so, please specify.

Are any of the children in braces? If so, please specify the child(ren), the orthodontist, any monthly payments, and which parent is making the payments.

Are there any private school expenses for the child(ren)? If so, please specify the child(ren) attending private school, the monthly costs, tuition costs, and which parent is making the tuition payments.

Do your children participate in any extracurricular activities? blanks
If yes, please answer the following:

Please break down the costs and provide the following details for each extracurricular activity:

Child:
Activity:
Expense:
Amount each parent pays/paid:

Child:
Activity:
Expense:
Amount each parent pays/paid:

Child:
Activity:
Expense:
Amount each parent pays/paid:

Child:
Activity:
Expense:
Amount each parent pays/paid:

Child:
Activity:
Expense:
Amount each parent pays/paid:

How much are you paying per year for each child's extracurricular activities?

How much is the other parent paying per year for each child's extracurricular activities?

Has more than a month elapsed between your date of separation and the present? blank
If yes, please answer the following:
Note: Payments "for the benefit of your child(ren)" would also include things such as mortgage payments and paying utilities at the former marital home. However, only a percentage of these payments would be for the child(ren).

Have you made any child support payment to or for the benefit of your child(ren) from the date of separation to the present?
If yes, what amount have you been paying each month?
What is the total amount of child support you have paid since your date of separation?

Have you received any child support payments from the other parent for the benefit of your child(ren) from the date of separation to present?
If yes, what amount have you been receiving each month?
What is the total amount of child support you have received since your date of separation?

Please provide the following documents to our office. Keep in mind that these documents will need to be updated prior to any mediation or trial dates. This process will be much easier if you keep these types of documents filed or stored in a convenient area, so that when we are preparing for mediation or future hearings, you can locate them easily.

If you are an hourly or salaried employee (including if you receive bonuses and commissions in addition to your salaried income), please provide the following documents:

File Upload

For all other persons (i.e. self-employed, business owners, professional practice partners, etc.) please provide the following documents:

File Upload

CHILD SUPPORT QUESTIONNAIRE

YOUR INCOME

OTHER PARENT'S INCOME

EXPENSES FOR THE CHILD(REN)

CHECKLIST OF DOCUMENTS FOR CHILD SUPPORT