The DCSS 0321 V1 form, also known as the Non IV-D Family Violence Questionnaire, is an essential document issued by the State of California’s Health and Human Services Agency specifically through the Department of Child Support Services. This form plays a critical role in ensuring the safety and confidentiality of those involved in child support cases who may also be victims of family violence or child abuse. By providing an opportunity to disclose instances of abuse and to request the non-disclosure of identifying information, the form acts as a protective measure for victims. It is designed to prevent the inadvertent release of sensitive information that might put them at further risk. The form is divided into sections that require detailed information about the violence or abuse experienced, existing protective orders against the other party, and an explicit request regarding the disclosure of the victim’s location or identifying information. The importance of this form cannot be overstated, as failure to complete and return it could result in the disclosure of information to courts, child support agencies, and potentially the individual responsible for the abuse. Additionally, the form includes a privacy notice in compliance with both the Information Practices Act of 1977 and the Federal Privacy Act of 1974, emphasizing the legal obligations to protect individuals' privacy while also detailing the consequences of non-compliance. The document’s clear instructions underscore its goal to provide victims of family violence within child support cases a secure way to communicate their circumstances and protect their privacy.
| Question | Answer |
|---|---|
| Form Name | Form Dcss 0321 V1 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | dcss 0321 v1 form, MS-51, DCSS, V1 |
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY |
DEPARTMENT OF CHILD SUPPORT SERVICES |
NON
DCSS 0321 V1 (06/14//06)
INSTRUCTIONS: If you do not complete and return this form to us, the Department of Child Support Services, or the federal government, may give information about your case to courts, child support agencies, and possibly to the child(ren)’s other parent or party.
Your name:Case Number: ________________________________
Other parent or party’s name: ___________________________________
SECTION I - Check the appropriate box for each of the questions.
1.Have you or a child in your care ever been a victim of family violence or child abuse committed by the other parent or party to this child support case?
No
Yes If yes, Sections II and III must be completed.
2.Do you have a restraining order, emergency protective order or stay away order currently in effect and in place against the other parent or party to this child support case?
No If no, please complete Section III.
Yes If yes, please see the instructions below.
(1)Attach a copy of the order
(2)Please provide the following information:
Police Agency / County / State
Court Case Number
Expiration Date
(3) Sections II and III must be completed
SECTION II - You MUST complete this section if you answered “Yes” to Questions number 1 or 2 in
SECTION I.
Please provide detailed family violence information. Please include as much information as possible, such as date(s), time(s), location(s), names of any witnesses for each incident, what happened, the person(s) involved, each person’s actions, any injuries, any medical or other services you sought. When completing this section, if additional pages are needed, attach a sheet which includes your name and case number. You must also sign and date the additional sheet(s).
Page 1 of 2
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY |
DEPARTMENT OF CHILD SUPPORT SERVICES |
NON
DCSS 0321 (06/07/06)
SECTION III – Please check the appropriate box below.
Giving out my address or other information identifying my location could be harmful to me or the child(ren) in my care. I am requesting that my address or other identifying information not be given to the other parent or party in this case. (This request will stay in effect until I let the Department of Child Support Services know in writing that they may now give out my information, and the Department of Child Support Services tells me that they have received my request.) I understand that under federal law, an authorized person may give a written request to the court that has jurisdiction to make or enforce child support or visitation determinations, for release of my information. You will be notified in writing, if the court orders the release of any information on my case.
The disclosure of my address or other information identifying my location is not harmful to me or the child(ren) in my care. I understand this information will be made available to the federal government, courts, child support agencies, and sometimes to the other parent or party of the child(ren).
Sign, date, and return the form to:
Department of Child Support Services
FV Unit,
P.O. Box 419084
Rancho Cordova, CA
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
PRINT NAME |
SIGNATURE |
DATE |
If you have any questions or concerns regarding this notice, please call us at
PRIVACY NOTICE
The Information Practices Act of 1977 (Civil Code §1798.17) and the Federal Privacy Act of 1974 (Title 5, United States Code §552a(e)(3), §7 Note) require that this notice be provided when collecting personal information from individuals. Information requested on this form is used by the Department of Child Support Services and local child support agencies for the purpose of safeguarding information from disclosure in domestic and/or child abuse situations. The information you provide may be given to the federal government, and other public agencies to the extent required by law. Failure to provide this information will limit the DCSS’ ability to safeguard your information.
The agency official responsible for maintenance of the form is: DCSS Records Officer, PO Box 419064,
Page 2 of 2