Dcss 0095 Form PDF Details

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QuestionAnswer
Form NameDcss 0095 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesquestionnaire paternity, dcss95 form, california dcss form dcss form 0095, support paternity questionnaire blank

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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 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

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:

 

 

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

 

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

 

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 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.

Yes

No

 

 

 

 

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?

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 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:

 

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