The DCSS 0095 form, known as the Confidential Paternity Questionnaire, plays a crucial role in the State of California's efforts to ensure that children receive support from both parents. Initiated by the Department of Child Support Services (DCSS), this comprehensive form serves multiple purposes, including establishing paternity, identifying individuals for child support obligations, and facilitating communication between parents for the welfare of their child. The form is divided into parts, with each segment designed to collect detailed personal information about the mother, the child, and the alleged father. The information gathered is vital, not only for record-keeping but also for locating individuals and enforcing child support orders effectively. Notably, the DCSS emphasizes privacy and compliance with both the Information Practices Act of 1977 and the Federal Privacy Act of 1974, ensuring that personal data is used strictly for its intended purposes. From court orders regarding paternity to personal declarations and acknowledgments, the DCSS 0095 form requires respondents to provide thorough information, including social security numbers, to streamline the process of support and health insurance provision for the child involved. This form becomes an essential document for parents navigating the complexities of child support and paternity matters in California.
| Question | Answer |
|---|---|
| Form Name | Dcss 0095 Form |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | questionnaire paternity, dcss95 form, california dcss form dcss form 0095, support paternity questionnaire blank |
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY |
DEPARTMENT OF CHILD SUPPORT SERVICES |
CONFIDENTIAL PATERNITY QUESTIONNAIRE (PART I)
DCSS 0095 (08/16/04)
Please complete this form to the best of your ability.
Privacy Statement
CASE NAME
The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act of 1974 (Public Law
1. Please fill out the following personal information for the mother.
Name of Mother |
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Date of Mother's Birth |
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Address |
Street |
City |
State |
Zip Code |
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Social Security Number |
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Home Phone |
Work Phone |
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Message Phone |
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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 |
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Address |
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Last Known |
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Home |
Work |
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Message |
Phone |
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Last Known Employment (Type, Business Name)
Address of Last Known Employment
Physical
Description
Height
Weight
Hair Color
Eye Color
Complexion
Race
4. Are there any court orders naming the father of the child? |
Yes |
No |
If Yes, please explain below: |
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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? If Yes, explain below:
Yes
No
Name of husband |
Were you living with your husband |
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at the time you became pregnant? |
Yes
No
When did you separate?
Was your husband impotent or sterile at the time you became pregnant?
Yes
No
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 AGENCYDEPARTMENT 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 |
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not need to complete Parts II and III at this time. |
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1. Name of Mother |
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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? |
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Yes |
No |
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5. |
Has the father ever seen the child? |
If Yes, what did he say or do? |
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Yes |
No |
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6. |
Did the father give you any money or articles for |
Explain: |
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the child? |
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Yes |
No |
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7. |
Has the father ever lived with the child? |
If Yes, when and where? |
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Yes |
No |
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8. |
Did the father ever admit that the child was his? |
Explain: |
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Yes |
No |
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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 and letters) from the father referring to your pregnancy, to you as mother, or to the child?
Yes No
When?
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?
Yes |
No |
If Yes, give dates.
Date(s) and Address(es):
12. Were you and the father ever married? |
If Yes, date of marriage. |
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Yes |
No |
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Date of separation
13.Did you have any sexual intercourse with anyone else during the month, the month before or the month after you became pregnant?
Yes |
No |
If Yes, give name(s) and address(es).
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 acknowledge paternity and cooperate in establishment of paternity, you do not need to complete Parts II and III at this time.
CASE NAME
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?
Yes |
No |
If Yes, where and when?
Please give the name(s) and address(es) of anyone who saw you there together.
8. Did the father use any birth control method?
Yes No
If Yes, please list the method used.
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? |
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Yes |
No |
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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? |
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the father? |
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Yes |
No |
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Who else heard the discussions?
14.Did the father ever pay or promise to pay any other money to you during your pregnancy?
Yes |
No |
Explain:
Page 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT 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: |
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doctor, hospital, or medical bills related to your |
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pregnancy? |
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Yes |
No |
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16. |
Have you ever written to the father concerning the |
When? |
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child? |
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Yes |
No |
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What did you say? |
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17. Does the child resemble the father? |
In what way? |
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Yes |
No |
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18. |
Has the father ever claimed the child on his |
When? |
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income tax? |
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Yes |
No |
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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