Form DCSS 0069 PDF Details

Navigating through the complexities of child support can be daunting for many parents, and the DCSS 0069 form plays a crucial role in this journey within the State of California. This document, issued by the Department of Child Support Services, serves as a Child Care Verification form, providing a structured way for custodial and noncustodial parents to officially document the costs associated with child care. The requirement for the form arises when a parent, whether custodial or noncustodial, needs to verify child care expenses as part of a child support case. It meticulously records various details such as the provider's information, costs incurred per child, and specifies the payment frequency— displaying a comprehensive snapshot of childcare expenses. Furthermore, it captures the nuances of child care, presenting sections for both infant & pre-school children as well as school-age children, including adjustments for summer or vacation care. The form not only encourages transparency but also ensures that child support agreements or orders accurately reflect the financial contributions toward child care— a testament to the state's commitment to fostering a fair support system. By mandating the completion and submission of this form, along with any supporting receipts or evidence of payment, California underscores the importance of an equitable process in determining child support, aiming to protect the welfare of the child while balancing the financial capabilities of the parents.

QuestionAnswer
Form Name Form DCSS 0069
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names child care verification ca, dcss 0069, form dcss 0069, child care verification dcss 0069

Form Preview Example

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF CHILD SUPPORT SERVICES

CHILD CARE VERIFICATION

DCSS 0069 (02/10/09)

CSE Case Num:

Applicant Name:

I am the ___ Custodial Party

 

___ Noncustodial Parent

APPLICANT: Give this form to your childcare provider to complete before you return it to the local child support agency. Attach any receipts or copies of cancelled checks for child care.

CHILD CARE PROVIDER: Please complete the appropriate section(s) for the children of the above named applicant whom you provide child care. Then sign and date at the end of this form.

SECTION I: INFANT & PRE-SCHOOL CHILD(REN)

Name of Provider/Day Care Center___________________________________________________________________________________________

Address________________________________________________________________________________________________________________

City _______________________________________________________ State ____________ Zip _____________ Phone (____)_______________

Name of a person(s) that pays you for childcare_________________________________________________________________________________

Name of the child(ren) of this parent for whom you provide care and the amount paid:(Circle One)

Child _________________________________________________________ Amount $ _______________ per day/week/month

Child _________________________________________________________ Amount $ _______________ per day/week/month

Child _________________________________________________________ Amount $ _______________ per day/week/month

Total: $ _______________ per day/week/month

SECTION II: SCHOOL-AGE CHILD(REN)

A. Child care provided during regular school sessions:

Name of Provider/Day Care Center___________________________________________________________________________________________

Address________________________________________________________________________________________________________________

City _______________________________________________________ State ____________ Zip _____________ Phone (____)_______________

Name of a person(s) that pays you for childcare_________________________________________________________________________________

Name of the child(ren) of this parent for whom you provide care and the amount paid:(Circle One)

Child _________________________________________________________ Amount $ _______________ per day/week/month

Child _________________________________________________________ Amount $ _______________ per day/week/month

Child _________________________________________________________ Amount $ _______________ per day/week/month

Total: $ _______________ per day/week/month

Page 1 of 2

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF CHILD SUPPORT SERVICES

CHILD CARE VERIFICATION

DCSS 0069 (02/10/09)

B. Summer/vacation care for school-age child(ren). Include amounts in the information specified below.

Name of Provider/Day Care Center

Address

City

State

Zip

Phone (

)

Name of a person(s) who pays you for childcare

 

 

 

 

Name of the child(ren) of this parent for whom you provide care and the amount paid:

 

(Circle One)

 

Child

Amount $

 

per day/week/month

 

Child

Amount $

 

per day/week/month

 

Child

Amount $

 

per day/week/month

 

 

Total: $

 

per day/week/month

 

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. By typing my name in the signature line, I agree that the entry of that name is deemed to be my signature for all legal and administrative purposes.

SIGNATURE

DATE

Page 2 of 2

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When it comes to blank fields of this specific document, here is what you should know:

1. While submitting the how to child care verification, make sure to incorporate all important blanks within its associated form section. This will help to expedite the process, allowing for your information to be handled efficiently and properly.

Stage # 1 of completing verification of child care form

2. Once this segment is complete, you'll want to put in the necessary specifics in Name of the children of this, Total per dayweekmonth, SECTION II SCHOOLAGE CHILDREN, A Child care provided during, Name of ProviderDay Care Center, Name of the children of this, and Total per dayweekmonth allowing you to progress to the 3rd step.

Stage no. 2 in completing verification of child care form

3. The next step is quite simple, B Summervacation care for, Name of ProviderDay Care Center, Address, City, Name of a persons who pays you for, State, Zip, Phone, Name of the children of this, Circle One, Child, Child, Child, Amount, and Amount - all of these blanks will need to be filled out here.

Stage # 3 for filling in verification of child care form

In terms of Circle One and Zip, be sure that you take a second look in this section. These two are the key ones in the file.

4. The next section needs your attention in the following parts: I declare under penalty of perjury, SIGNATURE, and DATE. It is important to type in all of the required information to move further.

Stage number 4 for completing verification of child care form

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