DCSS 0053 Visitation Verification Form PDF Details

Completed by: name of the person completing the form, and a check for Custodial Party or Noncustodial Parent

Case: CSE Case Number

Custody: Shared Custody, Visitation Only, or Neither: check one; then Yes or No for a court-ordered custody/visitation arrangement

Visitation: regular visitation from and to (day and time); Yes or No, with dates and times, for vacation, summer, holiday and overnight visitation

Documentation: either party may be required to provide documentation

Signature: print name, signature and date under the declaration that the above information is true and correct to the best of your knowledge and belief

Question	Answer
Form Name	DCSS 0053 Visitation Verification Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min
Edition	08/21/2016
Issuing agency	California Department of Child Support Services
Other names	DCSS 0053, DCSS0053, Visitation Verification, DCSS Visitation Verification Form

How to Fill Out Form DCSS 0053

Form DCSS 0053 at a glance

What it is: Form DCSS 0053, Visitation Verification, is a State of California Department of Child Support Services form. Part 1 is the actual visitation by the noncustodial parent.

Who signs: The Name of person completing form (the Custodial Party or the Noncustodial Parent) fills in PRINT NAME, SIGNATURE and DATE.

A filled-in Form DCSS 0053 example: a noncustodial parent verifies visitation

Form DCSS 0053 example filled out, example: a noncustodial parent verifies visitation — A noncustodial parent fills out Form DCSS 0053, the visitation verification. The last 12 months are June 2025 through May 2026. The picture shows the filled text boxes, and every value in it is made up. Each TOTAL box holds the sum of the hours above it.

How to fill out Form DCSS 0053, box by box

Case number and name of person completing form

Fill in the CSE Case Number and the Name of person completing form, and check I am the Custodial Party or Noncustodial Parent.

The last 12 months and number of hours

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.

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. 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.

Fill in TOTAL.

Part 2. Shared custody/visitation: check one

Part 2 of the form is SHARED CUSTODY/VISITATION.

CHECK ONE: Shared Custody, Visitation Only or Neither.

Visitation hours: regular visitation

Under VISITATION HOURS, Regular Visitation: fill in From (specify day of the week) at (specify time), and circle one of a.m./p.m.

Fill in To (specify day of the week) at (specify time), and circle one of a.m./p.m.

Vacation, summer, holiday and overnight visitation

Vacation Visitation: check Yes or No. If Yes, please specify dates/times.

Summer Visitation: check Yes or No. If Yes, please specify dates/times.

Holiday Visitation: check Yes or No. If Yes, please specify dates/times.

Overnight Visitation: check Yes or No. If Yes, please specify dates/times.

Court-ordered custody/visitation arrangement and additional information

Court-ordered custody/visitation arrangement: check Yes or No.

Write any Additional Information.

The information is true and correct, and I am aware

By signing you declare to the best of your knowledge and belief that the 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.

Sources

[1] Form DCSS 0053 (08/21/2016), Visitation Verification, California Department of Child Support Services (the Official source link on this page).

DCSS 0053: Visitation Verification Form