Dcss 0373 Application Form – Fill Out and Use This PDF

The DCSS 0373 Application form serves as a simplified application for child support services through the State of California's Health and Human Services Agency's Department of Child Support Services. It is designed to collect comprehensive information to assist in the processing and management of child support cases. Applicable to both custodial and noncustodial parties, the form requires detailed input on personal, financial, and family details to facilitate the establishment or enforcement of a child support order. For assistance in completing this crucial document for ensuring the well-being of your children, click the button below.

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Dcss 0373 Application Form PDF Details

The DCSS 0373 form, issued by the State of California's Health and Human Services Agency Department of Child Support Services, serves as a simplified application for child support services, pivotal for the initiation and modification of child support orders. Ensuring accurate and thorough completion of this form is crucial as it directly influences the processing of one's case. Applicants are urged to provide comprehensive details by answering each query, being instructed to mark "UNKNOWN" or "N/A" where applicable. Before embarking on this process, reviewing the Child Support Handbook and the Child Support Enforcement Program Notice is recommended for a clear understanding of both parental and agency responsibilities. The form seeks detailed information about the custodial party or guardian, the child or children in question, including their full names and any relevant paternity information, and the noncustodial parent, urging the provision of as much identifying and financial data as possible. This comprehensive approach not only facilitates the establishment of paternity and child support orders but also underscores the importance of substantiating information with additional documentation if the space provided is insufficient. By signing the form, applicants affirm the accuracy of their submissions and their engagement with the prescribed informational resources, setting the groundwork for the child support services' intervention.

Question	Answer
Form Name	Dcss 0373 Application Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	dcss 0373 fillable, child support confidential information form, 0373 dcss form, dcss 0064

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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 GUARDIAN AND CHILD(REN)

This section is about the person or party who has primary custody of the child(ren). Please complete the entire section. If you are the custodial party, be sure to give us a telephone number where you may be reached during the day.

If the children named in the application have different noncustodial parents, a separate application must be completed for each noncustodial parent. If you need additional space for any section, attach a separate sheet of paper or use the Comment Section provided at the end of the first page.

Please list all the child(ren) of the parents named for whom support services are being requested. Complete the full name of each child, including first name, middle name, last name, and suffix (Jr., Sr., III, etc.)

There are several questions within this section related to determining the biological father of the child(ren) named in the application. One question asks whether a Declaration of Paternity has been signed. The Declaration of Paternity is a legal form that, when signed (usually at the hospital or clinic) by both parents, says the man is the legal father. 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 court.

A second question asks whether a Paternity Judgment has been established. A Paternity Judgment is an order from the court that, through the legal process, determines the biological father of the child(ren). Determining the biological father is necessary before child support can be ordered by the court.

Comments: You may use this section as extra space, if needed, or add any additional information you think might help us establish or enforce an order for the child(ren). You may include information about the other person's temper, whether they own rifles or handguns, if they have made threats against you or the child(ren), etc.

FACTS ABOUT NONCUSTODIAL PARENT

If you are the Custodial Party, this section may require you to look through old papers to find some of the information requested. The more information we have in this section the better and faster we will be able to serve you.

If at all possible, please provide the noncustodial parent's Social Security Number or numbers. If you do not know the exact date of birth, provide the approximate age.

Please provide any and all financial information about the noncustodial parent. Attach additional page(s) as needed or use the Comment Section on the first page.

If you are the noncustodial party, be sure to give us a telephone number where you may be reached during the day.

SIGNATURE OF APPLICANT

We will not be able to open this case without your signature. Your signature indicates that you have answered the questions on the application to the best of your ability and that you want to open this case. It also indicates that you have read the information provided above the signature line carefully.

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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)

APPLICANT NAME (PERSON COMPLETING THIS FORM)

I AM THE:

CUSTODIAL PARTY

NONCUSTODIAL PARENT

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)		YES	NO			A.M.	P.M.

			TELEPHONE NUMBERS			BEST NUMBER TO BE
	FATHER	MOTHER	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,

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

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

NONE

DATE OF DIVORCE

COUNTY

STATE

NONE

NONCUSTODIAL PARENT

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

1. Has noncustodial parent ever lived in California? . . . . . . . . . . .

2. Has noncustodial parent ever worked in California? . . . . . . . . .

3. In which state were the child(ren) conceived?

YES	NO	If "YES", When? ________	Where? ________
YES	NO	If "YES", When? ________	Where? ________

(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?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Was a Paternity Judgment established? . . . . . . . . . . . . . . . . . .

YES	NO	DON'T KNOW	If "YES", Where? ______________
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
From:	To:		CASH AID? (WELFARE)
			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
NAME	SEX	BIRTHDATE	BIRTHPLACE (CITY AND STATE)		NUMBER	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

MAIDEN NAME (IF APPROPRIATE)

RELATIONSHIP TO CHILD(REN)

TELEPHONE NUMBERS

FATHER

HOME:

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

Currently in jail or prison?

YES

If "YES", provide information below:

DATE

AGENCY

CITY

STATE

OFFENSE (REASON)

Is the noncustodial parent a US citizen?

YES

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

CURRENT AS OF

AVAILABLE FOR

ADDRESS OF PRESENT EMPLOYER (STREET, CITY, STATE AND ZIP CODE)

(DATE)

CHILDREN?

YES

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

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These areas will make up the PDF template that you will be filling out:

completing for simplified application child support step 1

Fill out the There are several questions within, A second question asks whether a, If you are the noncustodial party, SIGNATURE OF APPLICANT, We will not be able to open this, and Page of fields with any details that may be asked by the system.

stage 2 to completing for simplified application child support

You may be expected to note the details to help the software prepare the section SIMPLIFIED APPLICATION FOR CHILD, DCSS, APPLICANT NAME PERSON COMPLETING, I AM THE, CUSTODIAL PARTY, NONCUSTODIAL PARENT, NOTE The custodial party is the, FACTS ABOUT CUSTODIAL PARTY OR, NAME OF TRIBE, MAIDEN NAME IF APPROPRIATE, RELATIONSHIP TO CHILDREN, NAME OF CURRENT SPOUSE, FATHER OTHER SPECIFY, MOTHER, and ADDRESS STREET CITY STATE AND ZIP.

for simplified application child support SIMPLIFIED APPLICATION FOR CHILD, DCSS, APPLICANT NAME PERSON COMPLETING, I AM THE, CUSTODIAL PARTY, NONCUSTODIAL PARENT, NOTE The custodial party is the, FACTS ABOUT CUSTODIAL PARTY OR, NAME OF TRIBE, MAIDEN NAME IF APPROPRIATE, RELATIONSHIP TO CHILDREN, NAME OF CURRENT SPOUSE, FATHER OTHER SPECIFY, MOTHER, and ADDRESS STREET CITY STATE AND ZIP blanks to complete

You should spell out the rights and obligations of each side in field Date and place of marriage If, COUNTY, STATE, Date and place of divorce If no, STATE, NONE, NONE, If parents were NOT married please, If YES When Where If YES When, If YES Where If YES Where, DONT KNOW DONT KNOW, YES YES, YES YES, NO NO, and NO NO.

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End by analyzing the following sections and preparing them as needed: NAME, SEX, BIRTHDATE, BIRTHPLACE CITY AND STATE, SOCIAL SECURITY NUMBER, CHILDREN LIVING WITH YOU, YES, YES, YES, YES, List full names of other minor, NAME, BIRTHDATE, CHILDREN LIVING WITH YOU, and YES.

NAME, SEX, BIRTHDATE, BIRTHPLACE CITY AND STATE, SOCIAL SECURITY NUMBER, CHILDREN LIVING WITH YOU, YES, YES, YES, YES, List full names of other minor, NAME, BIRTHDATE, CHILDREN LIVING WITH YOU, and YES in for simplified application child support

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