Form Dcss 0069 PDF Details

Form Dcss 0069 is a document that is used in the state of Texas to declare the existence of a document. This document can be used to prove that a particular piece of paper exists and was created on a specific date. The form must be completed and filed with the county clerk's office where the document resides. Completing this form is simple, and can be done quickly and easily using an online filing service. By filing this form, you will have peace of mind knowing that your important documents are properly documented and accounted for.

QuestionAnswer
Form NameForm Dcss 0069
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameschild 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

Step 3: Prior to obtaining the next stage, make sure that all blank fields were filled in the correct way. The moment you verify that it is fine, press “Done." Sign up with us now and immediately access how to child care verification, ready for download. Every last change you make is conveniently kept , letting you customize the file at a later point as required. FormsPal ensures your data confidentiality by using a secure system that in no way records or shares any sort of private information provided. Feel safe knowing your paperwork are kept confidential when you work with our tools!

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