Fillable INSTRUCTIONS FOR COMPLETING THE SIMPLIFIED APPLICATION FOR CHILD (California)

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INSTRUCTIONS FOR COMPLETING THE SIMPLIFIED APPLICATION FOR CHILD (California)

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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.
This page intentionally left blank
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES
SIMPLIFIED APPLICATION FOR CHILD SUPPORT SERVICES
DCSS 0373 (07/12/13)
I AM THE: CUSTODIAL PARTY NONCUSTODIAL PARENT
APPLICANT NAME (PERSON COMPLETING THIS FORM)
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)
MAIDEN NAME (IF APPROPRIATE)
NAME OF CURRENT SPOUSE
RELATIONSHIP TO CHILD(REN)
FATHER
MOTHER
OTHER (SPECIFY)
TRIBAL
MEMBER
YES
NO
NAME OF TRIBE
BEST TIME TO
BE REACHED
A.M.
P.M.
TELEPHONE NUMBERS
HOME:
WORK:
CELL:
BEST NUMBER TO BE
REACHED AT
HOME 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
Page 2 of 3
STATE BIRTHDATE OR
APPROXIMATE AGE
PLACE OF BIRTH RACE PRIMARY LANGUAGE
SPOKEN IN HOME
GENDER:
FEMALE
MALE
NAME OF PRESENT EMPLOYER - IF NOT CURRENTLY WORKING, PRINT
"UNEMPLOYED" HERE
JOB TITLE OR OCCUPATION
GROSS MONTHLY EARNINGS
$
ADDRESS OF PRESENT EMPLOYER (STREET, CITY, STATE, AND ZIP CODE)
IS HEALTH INSURANCE AVAILABLE
FOR CHILDREN?
YES
NO
NAME AND TELEPHONE NUMBER OF A
RELATIVE OR FRIEND
Date and place of marriage (If never married, check "None")
DATE OF MARRIAGE TO
NONCUSTODIAL PARENT
COUNTY STATE
NONE
Date and place of divorce (If no divorce, check "None")
DATE OF DIVORCE COUNTY STATE
NONE
If parents were NOT married, please answer questions 1-5 below.
1. Has noncustodial parent ever lived in California? YES
NO If "YES", When?
Where?
2. Has noncustodial parent ever worked in California?
YES
NO
If "YES", When? Where?
3.
In which state were the child(ren) conceived?
(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?. .
YES
NO DON'T KNOW
If "YES", Where?
5. Was a Paternity Judgment established? 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
From: To:
CITY AND STATE WHERE SERVICES RECEIVED
HAVE THE MINOR CHILDREN RECEIVED
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
$
PER WEEK
PER MONTH
DATE OF ORDER COUNTY
STATE
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
NUMBER
CHILD(REN) LIVING WITH YOU
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
. . . . . . . . . . .
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________
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FACTS ABOUT NONCUSTODIAL PARENT
FULL NAME (LAST, FIRST, MIDDLE, SUFFIX)
MAIDEN NAME (IF APPROPRIATE)
NAME OF CURRENT SPOUSE
TRIBAL MEMBER
YES NO
NAME OF TRIBE
RELATIONSHIP TO CHILD(REN)
FATHER
MOTHER
OTHER NAMES OR ALIASES OF NONCUSTODIAL PARENT
ADDRESS (STREET, CITY, STATE AND ZIP CODE)
TELEPHONE NUMBERS
HOME:
WORK:
CELL:
E-MAIL ADDRESS
CURRENT NOW
CURRENT AS OF (DATE)
SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER STATE BIRTHDATE OR APPROXIMATE
AGE
PLACE OF BIRTH GENDER
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
HAIR
EYES
COMPLEXION
HEIGHT
WEIGHT
PRIMARY LANGUAGE
IDENTIFYING FEATURES (MARKS, SCARS, TATTOOS, ETC.)
NAME OF PRESENT EMPLOYER (IF NOT WORKING, PRINT "UNEMPLOYED")
ADDRESS OF PRESENT EMPLOYER (STREET, CITY, STATE AND ZIP CODE)
CURRENT NOW
CURRENT AS OF
(DATE)
IS HEALTH
INSURANCE
AVAILABLE FOR
CHILDREN?
YES NO
GROSS MONTHLY
EARNINGS
$
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
MEMBER?
YES NO
NAME AND NUMBER OF UNION
ADDRESS OF UNION (STREET, CITY, STATE AND
ZIP CODE)
IF SELF-EMPLOYED, WHAT IS THE NAME OF THE BUSINESS?
STEADY WORKER? YES NO IF NO, EXPLAIN:
GROSS MONTHLY EARNINGS
$
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.
Page 3 of 3
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
Obtain a child support order
Enforce an existing child and spousal
support order (including past due)
Modify an existing child support order
Obtain an order for medical insurance
Enforce an existing medical insurance
order
No medical insurance enforcement
needed at this time. The children have
satisfactory medical insurance
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 pen
alty 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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INSTRUCTIONS FOR COMPLETING THE SIMPLIFIED APPLICATION FOR CHILD (California)

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Completed 26 July 2021

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