Ind. DeKalb Cnty. Local Rules App., Appendix 2, Health Insurance Premium Worksheet (HIPW)

IN RE:

CASE NO:

FATHER:

MOTHER:

| SECTION ONE: CALCULATION OF REASONABLE COST THRESHOLD | FATHER | MOTHER |

|---|---|---|

| A. Parent's Weekly Gross Income (from Line 1 of Child Support Worksheet) | $ | $ |

| B. Weekly Reasonable Cost Threshold (Line A x .05) | $ | $ |

| SECTION TWO: DETERMINATION OF PRIVATE HEALTH INSURANCE AVAILABLE TO THE PARENTS | [shaded] | [shaded] |

| C. Does the parent have private health insurance, for example, employer sponsored, available for the children? If the answer is No for a parent, STOP for that parent. | ☐ YES ☐ NO | ☐ YES ☐ NO |

| SECTION THREE: DETERMINATION OF WHETHER PREMIUM IS REASONABLE IN COST | [shaded] | [shaded] |

| D. What is the weekly premium for the children's portion only? | $ | $ |

| E. TEST ONE: Is Amount on Line D equal to or less than the Amount on Line B? If the answer is No for a parent, STOP for that parent. If the answer is Yes for at least one parent, proceed to Line F for that parent(s). | ☐ YES 'The premium may be reasonable in cost. ☐ NO 'The premium on Line D is not reasonable in cost. | ☐ YES 'The premium may be reasonable in cost. ☐ NO 'The premium on Line D is not reasonable in cost. |

| F. TEST TWO: Is the parent's child support obligation from Line 4 of the Basic CSOW plus the weekly premium from Line D of the HIPW equal to or less than 50% of the Parent's Weekly Gross Income on Line A of the HIPW? Formula: Father: Line 4, CSOW ($______) + Line D, HIPW, ($_______) = $ _______ is equal to or less than Line A, HIPW $______ X .5 = $ _______ Mother: Line 4, CSOW ($______) + Line D, HIPW, ($_______) = $ _______ is equal to or less than Line A, HIPW $______ X .5 = $ _______ | ☐ YES 'The premium is reasonable in cost. Father may be ordered to provide health insurance ☐ NO 'The premium on Line D is not reasonable in cost. | ☐ YES 'The premium is reasonable in cost. Mother may be ordered to provide health insurance ☐ NO 'The premium on Line D is not reasonable in cost. |

| SECTION FOUR: ACCESSIBILITY OF THE INSURANCE | [shaded] | [shaded] |

| G. Is the insurance coverage accessible to the children? (See Guideline 7 for definition of accessible) | ☐ YES ☐ NO | ☐ YES ☐ NO |

| SECTION FIVE: PARENT(S) ORDERED TO PROVIDE HEALTH INSURANCE | [shaded] | [shaded] |

| H. Parent(s) ordered to provide health insurance for children. | ☐ FATHER ☐ MOTHER | |

| I. Parent(s) ordered to provide health insurance for children. | ☐ FATHER | $ |

| | ☐ MOTHER | $ |

| | TOTAL ORDERED | $ |