PARTICIPANT RESPONSIBILITY TO FILE DOCUMENTS WITH COURT AND

PROTECT CONFIDENTIAL INFORMATION

We may forward documents to court for you: While it is your responsibility to file documents related
to your case directly with the court, it is the policy of the Department of Child Support Services (Child
Support) to forward appropriate legal forms and supporting documents received from participants such
as yourself to the Superior Court for filing. Documents you return to Child Support for the purpose of
modifying your order may also be forwarded to court. Documents intended for the court but received
by Child Support will be routed to the court as a convenience to you. Documents forwarded to the
court from Child Support may also be served on the other party in the court case.

We cannot change information on paperwork we send to court: Documents filed with the court
may become a matter of public record. Child Support will not remove or change any information on
forms that are submitted for filing with the court, so please be aware that private information such as
your address or social security number on documents sent to the court by Child Support can become
public records that anyone may see.

We are not your attorney: Since current law does not allow any child support agency to provide legal
representation for you, you or your attorney are responsible for properly completing all forms prior to
filing them with the court or submitting them to Child Support. Incomplete or improper forms may not
be accepted by the court, and routing of completed documents from Child Support to the court as a
courtesy to you does not create an attorney-client relationship between you and Child Support.

Legal help is available: If you have any questions or concerns about private information on legal
forms and documents, we strongly encourage you to seek legal assistance or talk to your county's
Family Law Facilitator office for possible options.

If you have any questions, please visit Customer Connect at [Link]/CustomerConnect

for assistance on-line or call Customer Connect at 1-866-901-3212. Persons with hearing or
speech impairments, please call the TTY number at 1-866-399-4096.

PARTICIPANT RESPONSIBILITY TO PROTECT STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CONFIDENTIAL INFORMATION DEPARTMENT OF CHILD SUPPORT SERVICES
DCSS 0749 (02/24/2019)
This page intentionally left blank.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

NOTICE OF CHILD SUPPORT SERVICES PROGRAM

DCSS 0064 (10/20/2019)

WHAT THE CHILD SUPPORT PROGRAM CAN DO FOR YOU:

All children have the right to be supported by both parents. Any person, including a noncustodial parent, whether or not
he or she receives public assistance, can apply for support services. Some of the services available are:
• locating the parent(s) for child support enforcement purposes;
• establishing paternity (legal fatherhood);
• establishing a child and/or medical support (health insurance) order;
• enforcing a child and/or medical support order;
• changing an existing court order for child and/or medical support;
• enforcing a spousal support order with a child support order;
• collecting and distributing support payments.

Custody and visitation services are not provided.

The local child support agency provides services on behalf of the county. The local child support agency does
not represent you and is not your attorney. Because you are not its client, the local child support agency may
provide enforcement services to you or the other parent in the future, and the information you provide is not
privileged or kept confidential under attorney-client privilege.

COOPERATION WITH CHILD SUPPORT

When you request services, you must cooperate with the local child support agency by providing any information or
documents needed to establish paternity and/or locate the other parent and to get support payments for your child.
Once you request services of the local child support agency, the local child support agency will determine the
appropriate actions to take. All support payments must be made to the State Disbursement Unit. If payments are made
directly to you, these payments must be turned over to the State Disbursement Unit.

When you apply for, or receive support services, you are responsible for promptly informing the child support agency of
any changes that could affect your child support case or the work of the local child support agency. Some examples are:
• child leaves your home;
• telephone number or address changes (including a move to another county, state, or country);
• stopping public assistance, such as California Work Opportunity and Responsibility to Kids (CalWORKs);
• name change;
• initiation of divorce or other legal proceedings involving your child;
• information regarding the other party;
• direct receipt of any child, spousal or family support payment.

Pursuant to Title 45, Code of Federal Regulations, section 303.3, for all cases referred to a local child support agency
or where an application for services has been received, the agency must attempt to locate all noncustodial parents or
sources of income and/or assets when necessary for the next appropriate action. When applicable and appropriate, to
your case(s), the local child support agency will seek to obtain verification of Social Security Administration information
through a data matching process.

YOUR RIGHTS
You have the right to seek legal advice from a private attorney or legal services office at your own expense. If you hire
an attorney, you must tell the local child support agency. For free information and/or legal assistance, you may contact
the Superior Court’s Office of the Family Law Facilitator. Free or reduced cost legal services may also be available at
your local legal aid office.

If you have a support order in the State of California, you may ask the local child support agency to review your support
order to determine if the amount of support should be changed based on statewide guidelines. If the amount of support
does not meet guidelines for change, the local child support agency must give you or the other parent, upon request,
information on how to get the forms to request the court to change the amount of support ordered. The Family Law
Facilitator can also help free of charge. The local child support agency must tell you of the date, time, and purpose of
every hearing for paternity or support. You have the right to read the court file, unless that information is legally
prohibited by confidentiality requirements.

Page 1 of 3
[USER_ID]
Upon your request, the local child support agency may give you copies of the most recent order entered in your case
file. You can go to court to enforce your support order, but you must give the local child support agency advance notice
that you intend to file your own enforcement action. If the local child support agency does not respond to your notice
within thirty (30) days or if the local child support agency tells you that you can proceed, you can then file your own
enforcement action with the Superior Court as long as all support is payable through the State Disbursement Unit.

The local child support agency must have the permission of a non-public assistance recipient before filing a stipulation
affecting the support order in which that person is named as a party. The local child support agency cannot, without a
public assistance recipient’s consent, enter into a stipulation that will decrease the amount of overdue support when the
recipient is owed overdue support that is more than the amount of public assistance paid to the recipient.

If you are not receiving public assistance, the payments the State receives are applied in the following order:

1. Current monthly support;

2. Past due support;
3. Interest; and
4. Future obligations.

Federal income tax refunds owed to the noncustodial parent can be intercepted by the child support agency, and are
applied differently than other payments. By federal law, this money cannot be applied to current support obligations. It
must be applied to the past due child support. If a custodial party has received public assistance, including Medi-Cal,
the past due child support owed to the government will be paid first.

All case types that are eligible for Federal income tax refund offset are eligible for administrative offset. The following
types of payments are available for administrative offset. They include both recurring and nonrecurring payments.
Recurring payments are payments that are issued on a regular, routine, or repeated basis. A nonrecurring payment is
issued once and not expected to be repeated, such as a lump-sum retirement payment.

The Federal payments currently included in administrative offset are: Federal retirement payments, vendor, and
miscellaneous payments (i.e., expense reimbursement payments and travel payments).

Administrative Offset and Federal Tax Refund Offset are allowed by 31 United States Code section 3716, 42 United
States Code section 664, 26 United States Code section 6402, and 45 Code of Federal Regulations section 303.72.

State income tax refunds and lottery awards owed to the noncustodial parent can also be intercepted by the child
support agency and are applied according to the Child Support Program distribution regulations (Manual of Policy and
Procedures, sections 12-415 and 12-420). Franchise Tax Board intercept and lottery award collections are applied to all
current support and then to past due child support, including past due medical support.

Beginning October 1, 2020, pursuant to the Bipartisan Budget Act of 2018, section 53117 of Public Law 115-123 which
amended the provisions of the Federal Deficit Reduction Act of 2005, the Department of Child Support Services may
assess a $35 Annual Service Fee for each case that has never received public assistance. This fee will be assessed
every year on October 1st for each case in which at least $550 has been disbursed to the family in the prior Federal
Fiscal Year (October 1st - September 30th). The fee will be automatically deducted from the next payment(s) issued to
the custodial party after October 1st until the fee has been recovered in full.

Additionally, some other states charge a fee for services. If your case involves one of those states, they may
deduct the fee from the support payments, or add it to the balance that is owed.

NOTICE OF COLLECTIONS AND DISTRIBUTION

Custodial Party will get a Notice of Collections and Distribution of support payments every month. The Notice will show
all support that was collected and paid out during the period shown on the Notice, and if that money was applied to
current support, or past due support. A Notice of Collections and Distribution will not be sent in any month that no
support was received or paid out.

NOTICE OF CHILD SUPPORT SERVICES PROGRAM Page 2 of 3

DCSS 0064 (10/20/2019)
MEDICAL SUPPORT AND MEDI-CAL
Either or both parents can be required to provide health insurance if health insurance is available at a reasonable cost.
In general, the cost of health insurance is reasonable if it is employment-related group health insurance or other group
health insurance. However, in determining reasonable cost, the court will also consider the actual cost of the health
insurance to the parent(s).

The local child support agency will ask the court to establish or change a child support order to require the parent(s) to
provide health insurance if it is available at a reasonable cost. The custodial parent may also request that the local child
support agency change the child support order to include a provision for health insurance. This may affect the amount
of the monthly child support obligation. If the noncustodial parent is ordered to provide health insurance coverage, the
local child support agency will contact the noncustodial parent and his or her employer, if necessary, to secure health
insurance for the child. After the local child support agency receives the policy information, the information will be given
to the custodial parent.

Having private health insurance coverage does not prevent the Custodial Party from having Medi-Cal coverage. If the
Custodial Party receives Medi-Cal and has individual or group health private coverage (including dental or vision
coverage), the Custodial Party is required by federal and state law to tell the county welfare department (CWD), the
health care provider, and the child support agency. Failure to provide this information is a misdemeanor. The Custodial
Party must report to the CalWORKs eligibility worker and/or child support agency within ten (10) days when private
health coverage changes or stops. The Custodial Party must also tell the CalWORKs eligibility worker and/or child
support agency about any court order regarding health insurance.

If the Custodial Party is only receiving Medi-Cal, the Custodial Party must cooperate in establishing paternity and
obtaining medical support as a condition of continued eligibility for Medi-Cal benefits, unless the Custodial Party has filed
and the CWD has approved a claim of “good cause” (CW 51) Good Cause Claim for Noncooperation. Your child(ren) will
still be eligible for Medi-Cal. Also, all child support services will be given, unless the Custodial Party tells the local child
support agency that he or she does not want services that are unrelated to obtaining medical support and establishing
paternity. Obtaining medical support may reduce the amount of the child support received. In cases where both parents
are in the home, the local child support agency will establish paternity only.

Under Federal law [42 U.S.C. section 1396a(25)], health insurance belonging to a Medi-Cal recipient in a child or
medical support enforcement case is used as follows:

The service provider will bill Medi-Cal. Medi-Cal will pay the service provider. Then Medi-Cal will seek repayment from
the other health insurance coverage. You are not responsible for any insurance cost-sharing amount
(co-insurance, co-payment or deductible) unless a Medi-Cal co-payment or share of cost must be met. The provider
may bill you for the service if you do not cooperate in identifying your private health insurance. If your other health
insurance is a Prepaid Health Plan (PHP) or a Health Maintenance Organization (HMO), you must use the plan facilities
for regular medical care. Except for out-of-area service or emergency care, Medi-Cal will not pay for services provided by
a provider not associated with your PHP/HMO. Out-of-area services or emergency care should be billed to the
PHP/HMO.

For more information on Child Support Services, please refer to your Child Support Handbook.

NONDISCRIMINATION STATEMENT
It is the policy of the State of California to ensure that all individuals are treated equally and that no person shall, on the
basis of ethnic group identification, race, color, national origin, political affiliation or belief, religion, sex, age or disability
be excluded from participation in, denied the benefits of any program or service, or otherwise be subjected to treatment
that is different than that provided to others.

Each local child support agency has a designated Civil Rights Coordinator. Any applicant/recipient who feels they have
been subjected to discriminatory treatment may file a complaint of discrimination by first contacting the local child
support agency’s designated Civil Rights Coordinator through the State Customer Service Support Center (CSSC) or by
writing to the California Department of Child Support Services, Attn: Human Services Section, Civil Rights Office,
P.O. Box 419064, Rancho Cordova, CA 95741-9064 or call (866) 901-3212.

NOTICE OF CHILD SUPPORT SERVICES PROGRAM Page 3 of 3

DCSS 0064 (10/20/2019)
COMPLAINT RESOLUTION - STATE HEARING INFORMATION
RIGHT TO COMPLAINT RESOLUTION:
If you have a complaint against a local child support agency for any action or inaction regarding your child
support case, you have the right to request complaint resolution from the local child support agency.
You can make a complaint in writing by completing the Request for Complaint Resolution form, or you can
call the local child support agency.
IMPORTANT: Your request for complaint resolution must be made within 90 days from the date you
knew, or should have known, about the subject of your complaint.
The local child support agency has 30 days from the date it receives your complaint to give you a written
resolution of your complaint, unless the local child support agency needs more information or time to resolve
your complaint. The local child support agency will contact you if it needs more information or time to resolve
your complaint.
RIGHT TO A STATE HEARING:
If the local child support agency does not respond to you within 30 days from receiving your complaint, you
have the right to request a State Hearing before an Administrative Law Judge. IMPORTANT: Your request
for a State Hearing must be made within 90 days after you complained to the local child support agency.
If the local child support agency does respond to you within 30 days of making your complaint, and you are not
satisfied with the local child support agency's complaint resolution or response, you have the right to request a
State Hearing before an Administrative Law Judge. IMPORTANT: Your request for State Hearing must be
made within 90 days after you received the local child support agency's written response to your
complaint.
You can request a State Hearing in writing by sending a Request for State Hearing form to the State Hearing
Office, or you can call the State Hearing Office toll free at 1-866-289-4714.
The State Hearing Office will let you know the date, time, and place of your State Hearing.
The State Hearing Office will provide an interpreter or disability accommodation for you at the hearing if you
need one.
IMPORTANT: Not all complaints can be heard at a State Hearing.
State Hearings will only be granted for the following issues:
An application for child support has been denied or has not been acted upon within the required time frame.
The child support services case has been acted upon in violation of federal or state law or regulation, or
California Department of Child Support Services policy letter, or has not been acted on within the required
timeframe, including services for the establishment, modification, and enforcement of child support orders and
child support accountings.
Child support collections have not been distributed, or have been distributed or disbursed incorrectly, or the
amount of child support arrears, as calculated by the local child support agency is inaccurate.
The local child support agency's decision to close a child support case.
IMPORTANT: The following issues cannot be heard at a State Hearing:
Child support issues that must be addressed by motion, order to show cause, or appeal in a court.
A review of any court order for child support or child support arrears.
A court order or equivalent determination of paternity.
A court order for spousal support.
Child custody determinations.
Child visitation determinations.
Complaints of alleged discourteous treatment by a local child support agency employee, unless such
conduct resulted in a hearable action or inaction.
OMBUDSPERSON SERVICES:
Every local child support agency has an Ombudsperson available to help you through the complaint resolution
and/or State Hearing process.
The Ombudsperson can help you obtain information regarding your complaint to help you prepare for your
State Hearing.
IMPORTANT: The Ombudsperson cannot represent you at the State Hearing or give you legal advice.
COMPLAINT RESOLUTION - STATE HEARING INFORMATION STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DCSS 0642 (12/18/2016) DEPARTMENT OF CHILD SUPPORT SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

INSTRUCTIONS FOR COMPLETING THE SIMPLIFIED APPLICATION FOR CHILD

SUPPORT SERVICES
DCSS 0373 (07/12/13)

The processing of your case depends upon the information you provide on this form. Please provide as much
information as possible. Answer every question completely. If you do not know the answer, print "UNKNOWN."
If the question does not apply, print "N/A."

Before you begin, please read the Child Support Handbook. This book explains the services available through
the local child support agency. Also, read the Child Support Enforcement Program Notice. This notice explains
your responsibility to the local child support agency and the local child support agency's responsibility to you.
The local child support attorneys or Attorney General or any of their representatives are not your attorney or
the child(ren)'s attorney.

Please complete all the forms in BLACK INK and PRINT clearly.

FACTS ABOUT CUSTODIAL PARTY OR Comments: You may use this section as extra
GUARDIAN AND CHILD(REN) space, if needed, or add any additional information
you think might help us establish or enforce an order
This section is about the person or party who has for the child(ren). You may include information about
primary custody of the child(ren). Please complete the other person's temper, whether they own rifles or
the entire section. If you are the custodial party, be handguns, if they have made threats against you or
sure to give us a telephone number where you may the child(ren), etc.
be reached during the day.

If the children named in the application have FACTS ABOUT NONCUSTODIAL PARENT
different noncustodial parents, a separate
application must be completed for each If you are the Custodial Party, this section may
noncustodial parent. If you need additional space for require you to look through old papers to find some
any section, attach a separate sheet of paper or use of the information requested. The more information
the Comment Section provided at the end of the first we have in this section the better and faster we will
page. be able to serve you.

Please list all the child(ren) of the parents named for If at all possible, please provide the noncustodial
whom support services are being requested. parent's Social Security Number or numbers. If you
Complete the full name of each child, including first do not know the exact date of birth, provide the
name, middle name, last name, and suffix (Jr., Sr., approximate age.
III, etc.)
Please provide any and all financial information
There are several questions within this section about the noncustodial parent. Attach additional
related to determining the biological father of the page(s) as needed or use the Comment Section on
child(ren) named in the application. One question the first page.
asks whether a Declaration of Paternity has been
signed. The Declaration of Paternity is a legal form If you are the noncustodial party, be sure to give us
that, when signed (usually at the hospital or clinic) a telephone number where you may be reached
by both parents, says the man is the legal father. during the day.
Signing the form and submitting it to the Department
of Child Support Services legally establishes the
man as the child's father without having to go to SIGNATURE OF APPLICANT
court.
We will not be able to open this case without your
A second question asks whether a Paternity signature. Your signature indicates that you have
Judgment has been established. A Paternity answered the questions on the application to the
Judgment is an order from the court that, through best of your ability and that you want to open this
the legal process, determines the biological father of case. It also indicates that you have read the
the child(ren). Determining the biological father is information provided above the signature line
necessary before child support can be ordered by carefully.
the court.
Page 1 of 3
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

SIMPLIFIED APPLICATION FOR CHILD SUPPORT SERVICES

DCSS 0373 (07/12/13)
I AM THE: CUSTODIAL PARTY NONCUSTODIAL PARENT
APPLICANT NAME (PERSON COMPLETING THIS FORM) NOTE: The custodial party is the person or party who has
primary custody of the minor children.

FACTS ABOUT CUSTODIAL PARTY OR GUARDIAN AND CHILD(REN)

FULL NAME (LAST, FIRST, MIDDLE, SUFFIX) TRIBAL NAME OF TRIBE BEST TIME TO
MEMBER BE REACHED
YES NO A.M. P.M.
MAIDEN NAME (IF APPROPRIATE) RELATIONSHIP TO CHILD(REN)
TELEPHONE NUMBERS BEST NUMBER TO BE
FATHER MOTHER HOME: REACHED AT
NAME OF CURRENT SPOUSE OTHER (SPECIFY) WORK: HOME CELL
CELL: WORK
ADDRESS (STREET, CITY, STATE AND ZIP CODE) E-MAIL ADDRESS

Does the custodial party currently live with the noncustodial parent? YES NO (If "NO", give date and address last lived together)
DATE ADDRESS (STREET, CITY, STATE AND ZIP CODE)

SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER STATE BIRTHDATE OR PLACE OF BIRTH RACE PRIMARY LANGUAGE GENDER:
APPROXIMATE AGE SPOKEN IN HOME FEMALE
MALE
NAME OF PRESENT EMPLOYER - IF NOT CURRENTLY WORKING, PRINT JOB TITLE OR OCCUPATION GROSS MONTHLY EARNINGS
"UNEMPLOYED" HERE $

ADDRESS OF PRESENT EMPLOYER (STREET, CITY, STATE, AND ZIP CODE) IS HEALTH INSURANCE AVAILABLE NAME AND TELEPHONE NUMBER OF A
FOR CHILDREN? RELATIVE OR FRIEND
YES NO

Date and place of marriage (If never married, check "None") Date and place of divorce (If no divorce, check "None")
DATE OF MARRIAGE TO COUNTY STATE DATE OF DIVORCE COUNTY STATE
NONCUSTODIAL PARENT NONE NONE

If parents were NOT married, please answer questions 1-5 below.

1. Has noncustodial parent ever lived in California? . . . . . . . . . . . YES NO If "YES", When? ________ Where? ________
2. Has noncustodial parent ever worked in California? . . . . . . . . . YES NO If "YES", When? ________ Where? ________
3. In which state were the child(ren) conceived?
(Use number for each child listed below) . . . . . . . . . . . . . . . . . Child #____ State____ Child #____ State____ Child #____ State ____
4. Was a Declaration of Paternity signed at a California hospital
or agency?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO DON'T KNOW If "YES", Where? ______________
5. Was a Paternity Judgment established? . . . . . . . . . . . . . . . . . . YES NO DON'T KNOW If "YES", Where? ______________
Have services been provided by another child support agency? (If "YES", please give the date, city and state)
DATES OF SERVICES CITY AND STATE WHERE SERVICES RECEIVED HAVE THE MINOR CHILDREN RECEIVED
CASH AID? (WELFARE)
From: To:
YES NO

Is the noncustodial parent court ordered to pay child support for the child(ren) named below? YES NO PENDING
COURT ORDER # AMOUNT OF ORDER DATE OF ORDER COUNTY STATE
PER WEEK
$ PER MONTH

List full names of all minor children by this noncustodial parent (If child is not yet born, write "unborn", and expected date of birth).
(A separate application is required for children from another noncustodial parent)
IF CHILD IS NOT YET BORN, WRITE "UNBORN" HERE EXPECTED DATE OF BIRTH FOR UNBORN CHILD(REN)

NAME SEX BIRTHDATE BIRTHPLACE (CITY AND STATE) SOCIAL SECURITY CHILD(REN) LIVING WITH YOU
NUMBER
1. YES NO

2. YES NO

3. YES NO

4. YES NO

List full names of other minor child(ren) NOT related to this noncustodial parent
NAME BIRTHDATE CHILD(REN) LIVING WITH YOU

YES NO

YES NO

COMMENTS (Please attach a separate sheet if you need additional space)

APPLICATION ID: PLEASE COMPLETE BOTH SIDES Page 2 of 3

FACTS ABOUT NONCUSTODIAL PARENT
FULL NAME (LAST, FIRST, MIDDLE, SUFFIX) TRIBAL MEMBER NAME OF TRIBE
YES NO
MAIDEN NAME (IF APPROPRIATE) RELATIONSHIP TO CHILD(REN) TELEPHONE NUMBERS
HOME:
FATHER
NAME OF CURRENT SPOUSE WORK:
MOTHER
CELL:
OTHER NAMES OR ALIASES OF NONCUSTODIAL PARENT E-MAIL ADDRESS

ADDRESS (STREET, CITY, STATE AND ZIP CODE) CURRENT NOW

CURRENT AS OF (DATE)

SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER STATE BIRTHDATE OR APPROXIMATE PLACE OF BIRTH GENDER
AGE FEMALE
MALE
Currently on probation or parole? YES NO
Currently in jail or prison? YES NO If "YES", provide information below:
DATE AGENCY CITY STATE OFFENSE (REASON)

Is the noncustodial parent a US citizen? YES NO IF "NO", Please provide country of citizenship here:
PHYSICAL DESCRIPTION: (PLEASE PROVIDE PHOTO)
RACE COMPLEXION PRIMARY LANGUAGE
HAIR HEIGHT IDENTIFYING FEATURES (MARKS, SCARS, TATTOOS, ETC.)
EYES WEIGHT
NAME OF PRESENT EMPLOYER (IF NOT WORKING, PRINT "UNEMPLOYED") CURRENT NOW IS HEALTH GROSS MONTHLY
INSURANCE EARNINGS
ADDRESS OF PRESENT EMPLOYER (STREET, CITY, STATE AND ZIP CODE) CURRENT AS OF AVAILABLE FOR
(DATE) CHILDREN? $
YES NO
If unemployed or present employer is unknown, give name, address and telephone number of last employment below.
NAME OF LAST EMPLOYER ADDRESS OF LAST EMPLOYER (STREET, CITY, STATE AND ZIP CODE) TELEPHONE NUMBER (INCLUDE
AREA CODE)
USUAL OCCUPATION, TRADE, JOB TITLE OR SKILLS ACTIVE MILITARY: YES NO
WHAT BRANCH OF THE SERVICE?

IS THE NONCUSTODIAL PARENT A LABOR UNION NAME AND NUMBER OF UNION ADDRESS OF UNION (STREET, CITY, STATE AND
MEMBER? YES NO ZIP CODE)

IF SELF-EMPLOYED, WHAT IS THE NAME OF THE BUSINESS? GROSS MONTHLY EARNINGS

STEADY WORKER? YES NO IF NO, EXPLAIN: $

List any other sources of income or assets. (For example, Veterans Affairs benefits, Social Security Disability, interest, dividends, trust,
vehicles, boats, real estate, etc. Attach a separate sheet if necessary).

MOTHER'S MAIDEN NAME (LAST, FIRST) MOTHER'S STREET ADDRESS, CITY, STATE AND ZIP CODE MOTHER'S TELEPHONE
NUMBER

FATHER'S NAME (LAST, FIRST) FATHER'S STREET ADDRESS, CITY, STATE AND ZIP CODE FATHER'S TELEPHONE
NUMBER

Name and address of current spouse, friend, or relative.

NAME RELATIONSHIP STREET ADDRESS, CITY, STATE ZIP CODE TELEPHONE NUMBER

Is there visitation with the children? YES NO If "YES", how many times per month?
Is there any other child support obligation(s)? YES NO If "YES", please provide amount: $
Is there any other minor child(ren) in the home? YES NO If "YES", how many children?
Present marital status: Single Married Divorced Separated Living with another person
I request the services of the Department of Child Support Services to assist me in the following efforts: (Mark all that apply)
Establish paternity Modify an existing child support order No medical insurance enforcement
Obtain a child support order Obtain an order for medical insurance needed at this time. The children have
Enforce an existing child and spousal Enforce an existing medical insurance satisfactory medical insurance
support order (including past due) order coverage through: Custodial Parent
Noncustodial Parent
I am applying for support services under the Child Support Program of Title IV-D of the Social Security Act. I declare under penalty of
perjury (Penal Code, Section 118) that this questionnaire has been examined by me and to the best of my knowledge and belief it is true and
correct.
SIGNATURE OF APPLICANT DATE

Page 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

CONFIDENTIAL PATERNITY QUESTIONNAIRE (PART I)

DCSS 0095 (08/16/04)

CASE NAME
Please complete this form to the best of your ability.
Privacy Statement

The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act of 1974 (Public
Law 93-579) requires that this notice be provided when collecting personal information from individuals.
Information requested on this form, including your Social Security Number, is used by the Department of Child
Support Services (DCSS) for purposes of identification and communication with you. The DCSS is required,
under Section 466(a)(13) of the Social Security Act, to collect the Social Security Number of any individual who
is subject to a divorce decree, support order, or paternity determination or acknowledgement. Social Security
Number information is mandatory and will be kept on file at the local child support agency to locate and identify
individuals and assets for the purpose of establishing, modifying, and enforcing child support obligations.
Enrolling a child in health insurance may require the release of the child's Social Security Number and mailing
address to the other parent's employer or the release of the child's Social Security Number to the other parent.
The information in your case may be discussed with or given to the State, other public agencies that can legally
receive such information, and to the other parent or his/her attorney to the extent required by law.

1. Please fill out the following personal information for the mother.
Name of Mother Date of Mother's Birth

Address Street City State Zip Code

Social Security Number Home Phone Work Phone Message Phone

2. Please fill out the following personal information for the child.
Name of Child Date of Birth (or Expected Date)

Place of Birth Social Security Number

3. Please fill out the following personal information for the father.
Name of Father Date of Birth

Last Known Street City State Zip Code

Address
Last Known Home Work Message
Phone
Last Known Employment (Type, Business Name)

Address of Last Known Employment

Physical Height Weight Hair Color Eye Color Complexion Race

Description

4. Are there any court orders naming the father of the child? Yes No
If Yes, please explain below:
Name of Court Court Date Case Number

(Name of father if determined by the court and address if other than above)
Result:
Amount of child support awarded:

If the court has determined paternity, or a signed Declaration of Paternity is filed with
the State of California, no further answers are required. Sign at the end of the form.
Page 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

CONFIDENTIAL PATERNITY QUESTIONNAIRE (PART I)

DCSS 0095 (08/16/04)

5. Were you married when you became pregnant? Yes No

If Yes, explain below:
Name of husband Were you living with your husband Yes No
at the time you became pregnant?
When did you separate? Was your husband impotent or sterile Yes No
at the time you became pregnant?

If you were living with your husband at the time you became pregnant and he was not
impotent or sterile, then no further answers are required, sign below. If not, complete
PART II after signing below.
6. Comments

I declare under penalty of perjury that the information on this form is true to the best of my knowledge
and belief.
Signature Date: (MM/DD/YYYY)

Executed at City County State

Note: If you signed outside of the State of California, this form should be notarized.

Page 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

CONFIDENTIAL PATERNITY QUESTIONNAIRE (PART II)

DCSS 0095 (08/16/04)

If the father of your child(ren) is with you at your interview and will legally CASE NAME
acknowledge paternity and cooperate in establishment of paternity, you do
not need to complete Parts II and III at this time.

1. Name of Mother

2. Date you became pregnant Where?

Why do you believe that this date is correct?

3. Name the father listed on the birth certificate

If this is not the same person named in PART I, Question 3, please explain.

4. Did the father agree to the use of his name on your child's birth certificate?
Yes No

5. Has the father ever seen the child? If Yes, what did he say or do?
Yes No

6. Did the father give you any money or articles for Explain:
the child?
Yes No

7. Has the father ever lived with the child? If Yes, when and where?
Yes No

8. Did the father ever admit that the child was his? Explain:
Yes No

Give the names and addresses of persons to whom the father has admitted paternity.

9. Is the father willing to sign a statement admitting that he is the father?

Yes No

10. Have you ever received correspondence (cards When?

and letters) from the father referring to your
pregnancy, to you as mother, or to the child?
Yes No

What did he say?

Page 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

CONFIDENTIAL PATERNITY QUESTIONNAIRE (PART II)

DCSS 0095 (08/16/04)

11. Did you and the father ever live together? If Yes, give dates.
Yes No

Date(s) and Address(es):

12. Were you and the father ever married? If Yes, date of marriage.
Yes No

Date of separation

13. Did you have any sexual intercourse with anyone If Yes, give name(s) and address(es).
else during the month, the month before or the
month after you became pregnant?
Yes No

14. Comments

I declare under penalty of perjury that the information on this form is true to the best of my knowledge
and belief.
Signature Day, Month, Year Signed

Executed at City County State

Note: If you signed outside of the State of California, this form should be notarized.

Page 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

CONFIDENTIAL PATERNITY QUESTIONNAIRE (PART III)

DCSS 0095 (08/16/04)

If the father of your child(ren) is with you at your interview and will legally CASE NAME
acknowledge paternity and cooperate in establishment of paternity, you do
not need to complete Parts II and III at this time.

1. Name of Mother Name of Father

2. Why do you believe this person is the father of your child?

3. When did you begin dating the father of your child?

4. When and in which city or town did you first have sexual intercourse with the father?

5. When and in which city or town did you last have sexual intercourse with the father?

6. Please give the name(s) and address(es) of people (friends, relatives, neighbors, landlord) who have seen
you with the father and where they saw you:

7. Did you ever register at a motel or hotel with the father? If Yes, where and when?
Yes No
Please give the name(s) and address(es) of anyone who saw you there together.

8. Did the father use any birth control method? If Yes, please list the method used.
Yes No
9. What was the date of your last menstrual period before this pregnancy?

10. What was the weight of the child at birth?

11. What was the name of your doctor during pregnancy?

Doctor's Address:

12. Was the father informed of your pregnancy? By whom?

Yes No
What did the father say?

Who else was present when he was informed?

13. Did you ever discuss your pregnancy condition with What was said?
the father?
Yes No
Who else heard the discussions?

14. Did the father ever pay or promise to pay any other Explain:
money to you during your pregnancy?
Yes No

Page 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

CONFIDENTIAL PATERNITY QUESTIONNAIRE (PART III)

DCSS 0095 (08/16/04)

15. Did the father ever pay or promise to pay any Explain:
doctor, hospital, or medical bills related to your
pregnancy?
Yes No
16. Have you ever written to the father concerning the When?
child?
Yes No
What did you say?

17. Does the child resemble the father? In what way?

Yes No
18. Has the father ever claimed the child on his When?
income tax?
Yes No
19. Comments

I declare under penalty of perjury that the information on this form is true to the best of my knowledge
and belief.
Signature Day, Month, Year Signed

Executed at City County State

Note: If you signed outside of the State of California, this form should be notarized.

Page 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

REQUEST FOR SUPPORT SERVICES

DCSS 0055 (10/20/2019)

CSE Case Number:

INSTRUCTIONS: Read carefully before signing below. Your signature is required in order for us to
open a case for you.
Beginning October 1, 2020, pursuant to the Bipartisan Budget Act of 2018, section 53117 of Public Law
115-123 which amended the provisions of the Federal Deficit Reduction Act of 2005, the Department of Child
Support Services may assess a $35 Annual Service Fee for each case that has never received public
assistance. This fee will be assessed every year on October 1st for each case in which at least $550 has
been disbursed to the family in the prior Federal Fiscal Year (October 1st - September 30th). The fee will be
automatically deducted from the next payment(s) issued to the custodial party after October 1st until the fee
has been recovered in full.

I want the local child support agency to help me get a child support order to establish paternity for the
child(ren) or enforce a support order I have.

I understand that I am applying for these services under the Child Support Services Program under Title IV-D
of the Social Security Act.
I will let the child support agency know right away:

When each child marries.

When each child reaches age 18 years and is no longer attending high school, or 19 years,
whichever happens first.
If my home address, mailing address, or telephone number changes.
If my employer, including name, address, and telephone number changes.
If my income changes.
If my status, cost, or availability of health insurance coverage changes.
If any information regarding the whereabouts of the other parent(s) changes.
If the parent(s) moves back in together with the children, or
If there is any change in custody, childcare or visitation.

I am aware that the local child support agency does not represent me, the other parent, or the children who
are the subject of this case. No attorney-client relationship exists between the local child support agency
and me, the other parent, or the children. No attorney-client relationship will arise if the local child support
agency provides the support services I have requested.

I declare under penalty of perjury that I have read, understand, and agree to all of the terms
specified above.

PRINT NAME SIGNATURE DATE

This page intentionally left blank.
Dear Applicant:

The Department of Child Support Services (DCSS) is required by law to send child support case
information to the federal government. The federal government maintains a data base that includes all
child support cases in the country. Upon request, the federal government will release case information
to other child support agencies; however, if you or the child(ren) in this case are the victim of family
violence, you may not want the release of your case information.

If you think that releasing information about your case to the federal government may cause physical or
emotional harm to you or the child(ren) in this case, please fill out the Family Violence Questionnaire
(DCSS 0048) and return it to your local child support agency. You must fill out the form completely in
order to process your request.

Please mail the completed form to: Local Child Support Agency

For interstate cases personal identification must be disclosed unless a nondisclosure order has been
filed. If you have informed us that you have obtained a protective or restraining order or been granted
good cause exception from cooperation, the local child support agency shall seek an "order of
nondisclosure" prior to sending an interstate application to the other state. A nondisclosure order will
prevent the release of your personal information to the other parties involved in your interstate case.

If you feel the release of your address or other personal information would pose a risk to you
or your child(ren)'s health, safety or liberty and do not possess a protective or restraining order or have
good cause exception, you may seek your own order of nondisclosure. This can be obtained through
your own legal counsel or with the assistance of the family law facilitator.

If you or the child(ren) in this case are not a victim of family violence, you do not have to return this form.
Also, it is important to understand that DCSS is prohibited by law from releasing your personal
information in this case to the other party without a court order. However, some documents that include
some of your personal information may be filed with the court.

If you have any questions, please visit CustomerConnect on the web, [Link]/CustomerConnect
for assistance on-line, or call CustomerConnect at 1-866-901-3212. Persons with hearing or speech
impairments, please call the TTY number 1-866-399-4096.

FAMILY VIOLENCE QUESTIONNAIRE COVER STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
DCSS 0049 (02/02/09) DEPARTMENT OF CHILD SUPPORT SERVICES
This page intentionally left blank.
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

FAMILY VIOLENCE QUESTIONNAIRE

DCSS 0048 (02/09/09)

INSTRUCTIONS: If you do not complete and return this form to us, the Department of Child Support
Services, or the federal government, may give information about your case to courts, child support
agencies, and possibly to the child(ren)’s other parent or party.

Your name: Case Number:

Other party’s name:

SECTION I: Check the appropriate box for each of the questions.

1. Have you or the child(ren) in this case ever been a victim of family violence
or child abuse committed by the other party in this child support case? Yes No

2. Do you have a restraining order, emergency protective order or

stay away order against the other party in this child support case? Yes No
If yes, please attach a copy of this order and provide the following
information:

County/State: Order/Docket Number:

Expiration Date:

3. If you or the child(ren) in this case receive public assistance, do you want
the welfare department to review this case to determine eligibility to close
this support case because of the increased risk of physical, sexual, or
emotional harm to you or the child(ren) in this case, by the other party?
This is called having “good cause” to close the support case. Yes No

SECTION II: You MUST complete this section if you answered “Yes” to any item in SECTION I.

Please provide detailed family violence information including dates, times, places, and witnesses.
(Attach additional page if needed).

Page 1 of 2
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

FAMILY VIOLENCE QUESTIONNAIRE

DCSS 0048 (02/09/09)

SECTION III: If appropriate please check the box below, sign, date, and return this form to:

Local Child Support Agency

Giving out my address or other information identifying my location could be harmful to me or the
child(ren) in this case. I am requesting that my address or other identifying information not be given
to the other party in this case. This request will stay in effect until I let the local child support agency
know in writing that they may now give out my information, and the local child support agencyt tells
me that they have received my request. I understand that under federal law, an authorized person
may make a written request to the court that has jurisdiction to make or enforce child support or
visitation determinations, for release of my information. The local child support agency will let me
know in writing if the court orders the release of any information on my case.

I declare under penalty of perjury under the laws of the State of California that the foregoing is
true and correct.

PRINT NAME SIGNATURE DATE

PRIVACY NOTICE

The Information Practices Act of 1997 (Civil Code §1798.17) and the Federal Privacy Act of 1974 (Title 5, United States Code §552a
(e)(3), §7 Note) require that this notice be provided when collecting personal information from individuals. Information requested on
this form is used by the Department of Child Support Services and local child support agencies for the purpose of safeguarding
information from disclosure in domestic and/or child abuse situations. The information you provide may be given to the federal
government, and other public agencies to the extent required by law. Failure to provide this information will limit the DCSS’ ability to
safeguard your information.

The agency official responsible for maintenance of the form is: DCSS Records Officer, PO Box 419064, MS-110, Rancho Cordova,
CA 95741, fax number (916) 464-5069. Legal references authorizing solicitation and maintenance of this personal information include
Title 22 California Code of Regulations §§112110(h), 112300, 112301, and 112302, as well as Family Code §17212. Copies of this
form are maintained in confidential files of the Department of Child Support Services or local child support agencies for 4 years and 4
month after the closure of your child support case. You have the right of access to this form upon request by faxing (916) 464-5069.

If you have any questions or concerns regarding this notice, please call us at 1-866-901-3212.

Page 2 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

VISITATION VERIFICATION
DCSS 0053 (08/21/2016)

CSE Case Number:

Name of person completing form: I am the Custodial Party Noncustodial Parent

PART 1. ACTUAL VISITATION BY THE NONCUSTODIAL PARENT

INSTRUCTIONS:
Complete the visitation history by filling in the last 12 months and number of hours for each month the noncustodial parent
visited with the child(ren). If visitation is different for each child(ren), please complete one form for each child.

Example: If the last 12 months are June 2014 through May of 2015, you will complete June through December on the left
side of the chart below. You would put 2014 for the year. Then you would complete the right side of the chart with
January through May and put 2015 for the year.

NUMBER OF HOURS NUMBER OF HOURS

THE NONCUSTODIAL THE NONCUSTODIAL
MONTH/YEAR PARENT VISITED WITH MONTH/YEAR PARENT VISITED WITH
THE CHILD(REN) EACH THE CHILD(REN) EACH
MONTH MONTH

January/ January/

February/ February/

March/ March/

April/ April/

May/ May/

June/ June/

July/ July/

August/ August/

September/ September/

October/ October/

November/ November/

December/ December/
TOTAL: TOTAL:

Page 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

VISITATION VERIFICATION
DCSS 0053 (08/21/2016)

PART 2. SHARED CUSTODY/VISITATION

CHECK ONE: Shared Custody Visitation Only Neither

VISITATION HOURS:

Regular Visitation:

(Circle one)
From (specify day of the week) at (specify time) a.m./p.m.

(Circle one)
To (specify day of the week) at (specify time) a.m./p.m.

Vacation Visitation: Yes No

If Yes, please specify dates/times:

Summer Visitation: Yes No

If Yes, please specify dates/times:

Holiday Visitation: Yes No

If Yes, please specify dates/times:

Overnight Visitation: Yes No

If Yes, please specify dates/times:

Court-ordered custody/visitation arrangement: Yes No

Additional Information:

I declare to the best of my knowledge and belief that the above information is true and correct. I am aware that
this information may be provided to the other parent for their verification and that either party may be
required to provide documentation.

PRINT NAME SIGNATURE DATE

Page 2 of 2
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

HEALTH INSURANCE INFORMATION

DCSS 0054 (04/27/05)

County: Phone: LCSA Case Number:

Noncustodial Parent:
Full Name (First, Middle, Last, Suffix) I am the
Custodial Party Noncustodial Parent
Employer
Address (Street) City, State, Zip Code

Phone Social Security Number

Employer (Name, street, city, state, zip code, phone)

INSTRUCTIONS: Please complete SECTION I if health insurance is provided or available by the Noncustodial Parent or employer.
SECTION II is about the other parent's insurance. Employers complete Sections I and III only. Please sign and date
the completed form.

SECTION I: YOUR HEALTH INSURANCE

HEALTH INSURANCE:
Do you currently have Health Insurance coverage? Yes No If Yes, please complete the following.
Health Insurance Company or Union (provide Union Local number) Provided by:
Custodial Party Noncustodial Parent
Employer Other:
Relationship:
Insurance Company's Address: Street, Apartment Number or Unit Number Telephone Number
(Address where claims are mailed) (include Area Code)

City State Zip Code Policy Number

Premium Amount $ Check One: Weekly Bi-Weekly Semi-Monthly

Amount You Pay $ Check One: Weekly Bi-Weekly Semi-Monthly
Amount Employer Pays $ Check One: Weekly Bi-Weekly Semi-Monthly
Amount of deduction applied to employee's Amount of deduction applied to dependent's portion of Cost to add additional child
portion of Health Insurance $ Health Insurance $ $
Dependent(s) Currently Covered By Health Insurance
Name (First, Middle, Last) Social Security Sex Date of Birth Policy Number(s) Start Date End Date
Number

1.

2.

3.

4.

5.

6.

Please check this box if names and policy numbers of additional dependents covered by your Health Insurance are listed on a
separate sheet. Please attach the sheet.
Not available to dependents

Page 1 of 3
 The Policy covers the following: (Check all that apply)
Doctor Visits Medicare Supplemental Specific Illness Prescription Drugs

Long Term Care Hospital Stays Hospital Outpatient Other (Specify):

(i.e., lab work, physical therapy)

DENTAL INSURANCE:
Do you currently have Dental Insurance coverage? Yes No If Yes, please complete the following.
Dental Insurance Company

Dental Insurance Company's Address: Street, Apartment Number or Unit Number (address where claims are mailed)

City State Zip Code Policy Number

Premium Amount $ Check One: Weekly Bi-Weekly Semi-Monthly

Amount You Pay $ Check One: Weekly Bi-Weekly Semi-Monthly
Amount Employer Pays $ Check One: Weekly Bi-Weekly Semi-Monthly
Amount of deduction applied to employee's Amount of deduction applied to dependent's Cost to add additional child
portion of Health Insurance $ portion of health insurance $ $
Dependent(s) Covered by Dental Insurance
Name (First, Middle, Last) Social Security Sex Date of Birth Policy Number(s) Start Date End Date
Number
1.

2.

3.

4.

5.

6.

Please check this box if names and policy numbers of additional dependents covered by your Dental Insurance are listed on a
separate sheet of paper. Please attach the sheet.
Not available to dependents
VISION INSURANCE:
Do you currently have Vision Insurance coverage? Yes No If Yes, please complete the following.
Vision Insurance Company

Vision Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City State Zip Code Policy Number

Premium Amount $ Check One: Weekly Bi-Weekly Semi-Monthly

Amount You Pay $ Check One: Weekly Bi-Weekly Semi-Monthly
Amount Employer Pays $ Check One: Weekly Bi-Weekly Semi-Monthly
Amount of deduction applied to employee's Amount of deduction applied to dependent's portion Cost to add additional child
portion of Health Insurance $ of health insurance $ $
Dependent(s) Covered by Vision Insurance
Name (First, Middle, Last) Social Security Sex Date of Birth Policy Number(s) Start Date End Date
Number
1.

2.

3.

4.

5.

6.

Please check this box if names and policy numbers of additional dependents covered by your Vision Insurance are listed on a
separate sheet. Please attach the sheet.
Not available to dependents

HEALTH INSURANCE INFORMATION Page 2 of 3

DCSS 0054 (04/27/05)
 SECTION II: OTHER PARENT'S INSURANCE

HEALTH INSURANCE:
Does the other parent currently provide Health Insurance coverage for the child(ren) or you? Yes No
If Yes, please complete the following information.

Health Insurance Company

Health insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City State Zip Code

DENTAL INSURANCE:
Does the other parent currently provide Dental Insurance coverage for the child(ren) or you? Yes No
If Yes, please complete the following information.
Dental Insurance Company

Dental Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City State Zip Code

VISION INSURANCE:
Does the other parent currently provide Vision Insurance coverage for the child(ren) or you? Yes No
If Yes, please complete the following information.
Vision Insurance Company

Vision Insurance Company's Address: Street, Apartment Number or Unit Number (Address where claims are mailed)

City State Zip Code

SECTION III: (MUST BE COMPLETED)

I have enclosed the insurance card(s)/information about the coverage for the child(ren).

At this time I do not have the insurance cards/information about the coverage for the child(ren). I will send the information to you when I get
it from the insurance company.

At this time there is no health insurance coverage available. I understand that if it becomes available, I will have to add my child(ren) onto
the plan and then notify the local child support agency of the coverage. Coverage is unavailable because:

Not offered Seasonal Part-Time Refused enrollment Unreasonable in cost Probationary period/date eligible

PRIVACY STATEMENT
The information Practices Act of 1997 (Civil Code Section 1798.17) and the Federal Privacy Act of 1974 (Public Law 93-579) require this notice be
provided when collecting personal information from individuals. Information requested on this form, including Social Security Number, is used by the
Department of Child Support Services (DCSS) for purposes of identification and communication with you. The DCSS is required, under Section 466
(a)(13) of the Social Security Act, to collect the Social Security Number of any individual who is subject to a divorce decree, support order, or paternity
determination or acknowledgement.

Social Security Number information is mandatory and will be kept on file at the local child support agency to locate and identify individuals and
assets for the purpose of establishing, modifying, and enforcing child support obligations. Enrolling a child in health insurance may require the
release of the child's Social Security Number and mailing address to the other parent's employer or the release of the child's Social Security
Number to the other parent.

The information in your case may be discussed with or given to the State, other agencies that can legally receive such information, and to the
other parent or his/her attorney to the extent required by law.

SIGNATURE DATE

PRINTED NAME TELEPHONE (include Area Code)

TITLE

HEALTH INSURANCE INFORMATION Page 3 of 3

DCSS 0054 (04/27/05)
This page intentionally left blank.
 FL-150
PARTY WITHOUT ATTORNEY OR ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY
NAME:
FIRM NAME:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:

PETITIONER:
RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:
CASE NUMBER:
INCOME AND EXPENSE DECLARATION

1. Employment (Give information on your current job or, if you're unemployed, your most recent job.)
a. Employer:
Attach copies
b. Employer's address:
of your pay
stubs for last c. Employer's phone number:
two months d. Occupation:
(black out e. Date job started:
Social f. If unemployed, date job ended:
Security g. I work about hours per week.
numbers). h. I get paid $ gross (before taxes) per month per week per hour.
(If you have more than one job, attach an 8 1/2-by-11-inch sheet of paper and list the same information as above for your other
jobs. Write "Question 1—Other Jobs" at the top.)

2. Age and education

a. My age is (specify):
b. I have completed high school or the equivalent: Yes No If no, highest grade completed (specify):
c. Number of years of college completed (specify): Degree(s) obtained (specify):
d. Number of years of graduate school completed (specify): Degree(s) obtained (specify):
e. I have: professional/occupational license(s) (specify):
vocational training (specify):
3. Tax information
a. I last filed taxes for tax year (specify year):
b. My tax filing status is single head of household married, filing separately
married, filing jointly with (specify name):
c. I file state tax returns in California other (specify state):
d. I claim the following number of exemptions (including myself) on my taxes (specify):
4. Other party's income. I estimate the gross monthly income (before taxes) of the other party in this case at (specify): $
This estimate is based on (explain):
(If you need more space to answer any questions on this form, attach an 8 1/2-by-11-inch sheet of paper and write the
question number before your answer.) Number of pages attached:
I declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and
any attachments is true and correct.
Date:

(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

Page 1 of 4
Form Adopted for Mandatory Use Family Code, §§ 2030–2032, 2100–2113,
Judicial Council of California
INCOME AND EXPENSE DECLARATION 3552, 3620–3634, 4050–4076, 4300–4339
FL-150 [Rev. January 1, 2019] [Link]
 FL-150
PETITIONER: CASE NUMBER:

RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:

Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax
return to the court hearing. (Black out your Social Security number on the pay stub and tax return.)

5. Income (For average monthly, add up all the income you received in each category in the last 12 months Average
and divide the total by 12.)
Last month monthly
a. Salary or wages (gross, before taxes)..................................................................................................... $
b. Overtime (gross, before taxes)................................................................................................................ $
c. Commissions or bonuses......................................................................................................................... $
d. Public assistance (for example: TANF, SSI, GA/GR) currently receiving .................................. $
e. Spousal support from this marriage from a different marriage federally taxable* $
f. Partner support from this domestic partnership from a different domestic partnership $
g. Pension/retirement fund payments.......................................................................................................... $
h. Social Security retirement (not SSI)......................................................................................................... $
i. Disability: Social Security (not SSI) State disability (SDI) Private insurance $
j. Unemployment compensation................................................................................................................. $
k. Workers' compensation............................................................................................................................ $
l. Other (military allowances, royalty payments) (specify): $

6. Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.)
a. Dividends/interest.................................................................................................................................... $
b. Rental property income........................................................................................................................... $
c. Trust income............................................................................................................................................ $
d. Other (specify): $

7. Income from self-employment, after business expenses for all businesses......................................... $

I am the owner/sole proprietor business partner other (specify):
Number of years in this business (specify):
Name of business (specify):
Type of business (specify):
Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your
Social Security number. If you have more than one business, provide the information above for each of your businesses.

8. Additional income. I received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and
amount):

9. Change in income. My financial situation has changed significantly over the last 12 months because (specify):

10. Deductions Last month

a. Required union dues.................................................................................................................................................... $
b. Required retirement payments (not Social Security, FICA, 401(k), or IRA).................................................................. $
c. Medical, hospital, dental, and other health insurance premiums (total monthly amount)............................................. $
d. Child support that I pay for children from other relationships....................................................................................... $
e. Spousal support that I pay by court order from a different marriage federally tax deductible*.......................... $
f. Partner support that I pay by court order from a different domestic partnership.......................................................... $
g. Necessary job-related expenses not reimbursed by my employer (attach explanation labeled "Question 10g")......... $

11. Assets Total

a. Cash and checking accounts, savings, credit union, money market, and other deposit accounts............................... $
b. Stocks, bonds, and other assets I could easily sell.......................................................................................................$
c. All other property, real and personal (estimate fair market value minus the debts you owe)..... $

* Check the box if the spousal support order or judgment was executed by the parties and the court before January 1, 2019, or if a court-ordered change
maintains the spousal support payments as taxable income to the recipient and tax deductible to the payor.

FL-150 [Rev. January 1, 2019] INCOME AND EXPENSE DECLARATION Page 2 of 4

 FL-150
PETITIONER: CASE NUMBER:

RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:

12. The following people live with me:

How the person is That person's gross Pays some of the
Name Age related to me (ex: son) monthly income household expenses?
a. Yes No
b. Yes No
c. Yes No
d. Yes No
e. Yes No

13. Average monthly expenses Estimated expenses Actual expenses Proposed needs
a. Home: h. Laundry and cleaning..................................... $
(1) Rent or mortgage.......... $ i. Clothes........................................................... $
If mortgage: j. Education....................................................... $
(a) average principal: $ k. Entertainment, gifts, and vacation.................. $
(b) average interest: $ l. Auto expenses and transportation
(insurance, gas, repairs, bus, etc.)................. $
(2) Real property taxes.................................. $
(3) Homeowner's or renter's insurance m. Insurance (life, accident, etc.; do not include
(if not included above).............................. $ auto, home, or health insurance)................... $
(4) Maintenance and repair........................... $ n. Savings and investments............................... $
o. Charitable contributions.................................. $
b. Health-care costs not paid by insurance........ $
p. Monthly payments listed in item 14
c. Child care....................................................... $
(itemize below in 14 and insert total here)..... $
d. Groceries and household supplies................. $ $
q. Other (specify):
e. Eating out....................................................... $
r. TOTAL EXPENSES (a–q) (do not add in
f. Utilities (gas, electric, water, trash)................ $ the amounts in a(1)(a) and (b)) $
g. Telephone, cell phone, and e-mail................. $ $
s. Amount of expenses paid by others

14. Installment payments and debts not listed above

Paid to For Amount Balance Date of last payment
$ $
$ $
$ $
$ $
$ $
$ $

15. Attorney fees (This information is required if either party is requesting attorney fees):
a. To date, I have paid my attorney this amount for fees and costs (specify): $
b. The source of this money was (specify):
c. I still owe the following fees and costs to my attorney (specify total owed): $
d. My attorney's hourly rate is (specify):
I confirm this fee arrangement.

Date:

(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

FL-150 [Rev. January 1, 2019] INCOME AND EXPENSE DECLARATION Page 3 of 4

 FL-150
PETITIONER: CASE NUMBER:

RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:

CHILD SUPPORT INFORMATION

(NOTE: Fill out this page only if your case involves child support.)

16. Number of children

a. I have (specify number): children under the age of 18 with the other parent in this case.
b. The children spend percent of their time with me and percent of their time with the other parent.
(If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)

17. Children's health-care expenses

a. I do I do not have health insurance available to me for the children through my job.
b. Name of insurance company:
c. Address of insurance company:

d. The monthly cost for the children's health insurance is or would be (specify): $
(Do not include the amount your employer pays.)

18. Additional expense for the children in this case Amount per month
a. Childcare so I can work or get job training.................................................................... $
b. Children's health care not covered by insurance........................................................... $
c. Travel expenses for visitation........................................................................................ $
d. Children's educational or other special needs (specify below):..................................... $

19. Special hardships. I ask the court to consider the following special financial circumstances
(attach documentation of any item listed here, including court orders): Amount per month For how many months?
a. Extraordinary health expenses not included in 18b................................... $
b. Major losses not covered by insurance (examples: fire, theft, other
$
insured loss)...............................................................................................
c. (1) Expenses for my minor children who are from other relationships and
$
are living with me..................................................................................
(2) Names and ages of those children (specify):

(3) Child support I receive for those children............................................... $

The expenses listed in a, b, and c create an extreme financial hardship because (explain):

20. Other information I want the court to know concerning support in my case (specify):

FL-150 [Rev. January 1, 2019] INCOME AND EXPENSE DECLARATION Page 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

DECLARATION OF SUPPORT PAYMENT HISTORY

DCSS 0569 (06/17/2018)

INSTRUCTIONS FOR COMPLETING THE DECLARATION

OF SUPPORT PAYMENT HISTORY

On the back of this page is the Declaration of the Support Payment History for your case. Please
provide the amount of support that was ordered by the court and the amount that was paid for each
month. These figures will help determine the amount of the past due support owed, if any.

Within the boxes on the bottom half of the page, please complete the:
• "Amount Ordered" column for each year
• Fill in the amount of support that was ordered by the court each month since your
order began. If there has been a change in your order, make sure each month reflects
the correct amount of support due.
• "Amount Paid" column for each year
• Fill in the dollar amount of support paid in that month. If more than one payment was
made in a given month, put the total dollar amount of support paid. Put the dollar
amount next to the month in which the payment was actually paid, and not the
month the payments were intended to cover. If needed, you may attach more
sheets.

Within the boxes on the bottom half on the page, only if it applies to your case, please complete
the:
• “Incarceration/Institutionalization History"
• Fill in the details of any time periods during which the other parent of your child was
involuntarily confined in a state prison, county jail, juvenile facility, mental health
facility, or other facility. If needed, you may attach additional sheets.

Please complete a separate page(s) for child support, spousal support, family support, medical
support, unreimbursed medical expenses, and other types of support not listed. DO NOT combine
child support and spousal support unless your court order combines the two support
payments into a "family" support order.

Be aware that this Declaration is not confidential and may be given to the other parent or party in
your case for review. If there is a disagreement regarding the payment history, the parties may be
required to present proof of payments, for example, cancelled checks, or receipts.

If you have questions and/or need assistance with child support forms, you can get free help from
your local court's Family Law Facilitator Office. Information for the Family Law Facilitator can be
found at the California Courts website at [Link]

Page 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES

DECLARATION OF SUPPORT PAYMENT HISTORY

DCSS 0569 (06/17/2018)

Person completing this form (name): I am the: Custodial Party

Noncustodial Parent
Support Payment History for (check one): Child Spousal Family
Unreimbursed medical expenses Medical Other (specify):

YEAR YEAR YEAR

AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT
ORDERED PAID ORDERED PAID ORDERED PAID

January
February
March
April
May
June
July
August
September
October
November
December

Incarceration/Institutionalization History
OTHER DETAILS, SUCH AS CHARGING
BEGIN DATE RELEASE DATE FACILITY/INSTITUTION OFFENSE(S), CONVICTION(S),
(MM/DD/YYYY) (MM/DD/YYYY) NAME AND LOCATION VICTIM NAME(S), COURT WHERE
SENTENCED, ETC.

I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct. I am aware that this may be provided to the other parent for their
verification and that either party may be required to provide documentation.

Signature: Date: CSE Case Number:

Page 2 of 2