Dcss 0373 Application Form PDF Details

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QuestionAnswer
Form NameDcss 0373 Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdcss 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)

 

 

 

 

 

 

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

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

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

 

 

 

 

 

 

 

 

 

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

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

 

 

 

 

 

 

 

 

 

 

CURRENT AS OF

AVAILABLE FOR

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

(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

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Having the goal of allowing it to be as simple to use as possible, we created our PDF editor. The procedure of filling the form 0373 dcss will be simple for those who check out the following actions.

Step 1: Find the button "Get Form Here" on this webpage and hit it.

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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.

step 4 to finishing for simplified application child support

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

Step 3: Press the Done button to make certain that your finalized form can be exported to any device you pick out or mailed to an email you specify.

Step 4: Come up with no less than a couple of copies of your form to remain away from all of the possible issues.

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