# Income Calculation Worksheet - Page 1 -

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Income Calculation Worksheet
WORK INCOME (EARNED) : PARENT #1 __________                         WORK INCOME (EARNED) : PARENT #2 __________

ONCE A MONTH                                           \$________    ONCE A MONTH                                          \$________

TWICE A MONTH (e.g., 1st and 15th)                     \$________    TWICE A MONTH (e.g., 1st and 15th)                    \$________
Multiply by 2                             \$_______                  Multiply by 2                                        \$_______

EVERY 2 WEEKS (e.g., every other Friday) \$________                  EVERY 2 WEEKS (e.g., every other Friday) \$________
Multiply by 2.167                         \$_______                  Multiply by 2.167                                  \$_______

EVERY WEEK (e.g., every Friday)                        \$________    EVERY WEEK (e.g., every Friday)                       \$________
Multiply by 4.33                                       \$_______     Multiply by 4.33                                      \$_______

OTHER COUNTABLE INCOME                                              OTHER COUNTABLE INCOME
(UNEARNED):\$________                                                (UNEARNED):\$________
(i.e., Alimony, Unemployment, Worker’s Compensation, SDI, etc.)     (i.e. Alimony, Unemployment, Worker’s Compensation, SDI, etc.)

TOTAL GROSS INCOME: Parent #2
TOTAL GROSS INCOME: Parent #1                      \$___________
\$____________

DEDUCTIONS                                                          DEDUCTIONS

Work Expense (deduct up to \$90)                \$___________         Work Expense (deduct up to \$90)               \$___________

Childcare Expense (if paid by this parent) \$___________             Childcare Expense (if paid by this parent) \$___________
•    If a child is less than 2 years old, deduct up to \$200. If a   •   If a child is less than 2 years old, deduct up to \$200. If a
child is 2 years old or older, deduct up to \$175.                  child is 2 years old or older, deduct up to \$175.
•    If parent pays less than \$200/\$175, deduct the actual          •   If parent pays less than \$200/\$175, deduct the actual
amount paid.                                                       amount paid.

Alimony RECEIVED (by this parent)               \$___________        Alimony RECEIVED (by this parent)              \$___________
•    Deduct up to \$50. Calculate amount by determining how          •   Deduct up to \$50. Calculate amount by determining how
many family members receive alimony/child support and              many family members receive alimony/child support and
divide \$50 by that number.                                         divide \$50 by that number.

Dependent Care (if paid by this parent) \$____________               Dependent Care (if paid by this parent) \$____________
•    For care of disabled dependents, up to \$175/dependent.         •   For care of disabled dependents, up to \$175/dependent.
•    If parent pays less than \$175, deduct the amount paid.         •   If parent pays less than \$175, deduct the amount paid.

Alimony/Child Support PAID (by this parent)                         Alimony/Child Support PAID (by this parent)
•    Deduct the actual/court-ordered amount paid, whichever is      •   Deduct the actual/court-ordered amount paid, whichever is
less                                                               less

\$___________                                                       \$___________

TOTAL PARENT DEDUCTIONS                          \$___________       TOTAL PARENT DEDUCTIONS                         \$___________

(Total Gross Income – Total Deductions) =                           (Total Gross Income – Total Deductions) =

Parent #1- Net Income                                               Parent #2- Net Income

\$____________                                                       \$____________

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Child 1              Child 2              Child 3
Parent’s Net Income
(From Reverse Side)                   Age______            Age______            Age______
Family Size_______   Family Size_______   Family Size_______

Parent #1                                             \$___________         \$___________         \$___________
(if counted for this child)
Parent #2                                             \$___________         \$___________         \$___________
(if counted for this child)

Total Parent Net Income
\$___________         \$___________         \$___________
(Box A)

Child’s Countable Income                         Child 1              Child 2              Child 3

Work Income (Earned)
• if not enrolled in school and over 14 years         \$___________         \$___________         \$___________
old
Other Countable Income (Unearned)                     \$___________         \$___________         \$___________
(i.e., Child Support, Soc. Sec. benefits, etc.)

Total Child Gross Income                      \$___________         \$___________         \$___________
(Box B)

Child’s Deductions                          Child 1              Child 2              Child 3

Work Expense
\$___________         \$___________         \$___________
• deduct up to \$90
Child Support Received by this child
•    Deduct up to \$50. Calculate amount by
determining how many family members              \$___________         \$___________         \$___________
\$50 by that number.

Total Child Deductions
\$___________         \$___________         \$___________
(Box C)

Total Parent Net Income
(Box A)                              \$___________         \$___________         \$___________
+
Total Child Gross Income
(Box B)                          + \$___________       + \$___________       + \$___________
-
Total Child Deductions
(Box C)                         - \$___________       - \$___________       - \$___________
Child 1 Net Income   Child 2 Net Income   Child 3 Net Income
Child Net Income
=\$___________        =\$___________        =\$___________

May be Eligible for:

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