Fill - Free fillable NOTICE AND AGREEMENT FOR Cooperation CHILD, SPOUSAL AND (California) PDF form

Benefits of Cooperation

Your cooperation can help you and your child(ren). Finding

the noncustodial parent and establishing paternity may give

you and your child(ren) rights to future social security, veter-

ans, or other benefits. The LCSA will continue enforcement

after you go off cash aid or Medi-Cal unless you make a

request in writing to the LCSA to stop.

Good Cause for Not Cooperating

• Good cause is the right to refuse to cooperate because it

is not in the best interests of you or your child(ren).

• You have the right to claim good cause for not

cooperating if you have an acceptable reason for refusing

to cooperate with the county and the LCSA.

• The back of this form gives you facts about good cause.

If you want more facts about good cause and/or refusal to

cooperate, ask your worker to explain them to you.

Penalty for Refusal to Cooperate

If you do not have good cause, there are penalties if you

refuse to assign support rights, refuse or fail to give the county

any support given to you by the noncustodial parent(s), or

refuse to cooperate with the LCSA, including in determining

paternity.

• For cash aid applicants/recipients:

If you refuse to assign support rights or refuse/fail to

give the county any support given to you, you will not

be eligible for cash aid or Medi-Cal. Your child(ren)

may still be eligible for aid/benefits and your case will

be referred to the LCSA.

If you refuse or fail to cooperate in the paternity or

support enforcement process, your family’s grant will

be lowered by 25 percent until you cooperate and you

may not get Medi-Cal. This penalty ends effective

the first day of the month in which you do cooperate.

• For applicants/beneficiaries of Medi-Cal Only: You

will not be eligible for Medi-Cal benefits, but your

child(ren) may still be eligible.

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

NOTICE AND AGREEMENT FOR

CHILD, SPOUSAL AND MEDICAL SUPPORT

Complete one form for each noncustodial

parent or alleged father.

Assignment and Cooperation Rules

You must assign (give to) the county any rights you may have

for:

• Any child or spousal support payments you get while

receiving cash aid.

• Medical support you get while getting Medi-Cal.

The receipt of a cash aid payment and/or Medi-Cal Benefits

Identification Card (BIC) will assign the past and present

support rights of all persons for whom you are requesting

cash aid and/or medical assistance. You will be sent facts on

the amount of support the county gets from the noncustodial

parent(s).

Cooperation

You must cooperate with the county and the Local Child

Support Agency (LCSA) to:

• Identify and locate any noncustodial parent/alleged father

in your case;

• Tell the county or LCSA any time you get facts about the

noncustodial parent/alleged father, such as place of

residence or work location;

• Agree to cooperate in the support enforcement process or

to claim good cause for refusing to cooperate by

completing this Notice and Agreement;

• Complete the Child Support Questionnaire (CW 2.1Q) for

each noncustodial parent or alleged father;

• Establish paternity and get child and/or spousal support;

• Submit to genetic testing if paternity is in question;

• Obtain any other payments or property due any member

of your assistance unit;

• Obtain medical support money from any noncustodial

parent and, if you get cash aid, obtain child support

money;

• Tell the county about medical coverage or money for

medical services paid by the noncustodial parent and

complete the Health Insurance Questionnaire form

(DHS 6155);

• Give the LCSA any medical support money from any

noncustodial parent, and any child/spousal support

money you get;

• Appear at the county or LCSA office to sign papers or

give required facts;

• Appear at hearings or in court when necessary;

• Fill out and sign an Attestation Statement, if asked by the

LCSA. On this form you declare under penalty of

perjury that you have given all the facts you know about

the noncustodial parent/alleged father. If you sign the

form and you do not report all the facts or give wrong

facts, you can be fined or sent to jail/prison.

Certification and Agreement:

• I understand my rights and responsibilities as written on this notice.

• I understand the rules for assigning support rights to the county.

• I also understand my right to claim good cause.

■■ I agree to cooperate with the county and the LCSA as listed above

■■ I claim good cause and refuse to cooperate at this time.

NAME OF NONCUSTODIAL PARENT/ALLEGED FATHER

Signature of Parent or Caretaker Relative,

or Medi-Cal Applicant/Beneficiary

Case Number

Case Name

I certify that I have notified the applicant, cash aid recipient, or Medi-Cal beneficiary of his/her rights and responsibilities by

means of this notice and orally as needed.

County Worker’s Signature Worker’s Number

CW 2.1 NOTICE AND AGREEMENT (8/04) REQUIRED FORM - SUBSTITUTE PERMITTED

Date

■■ I refuse to assign child/spousal support rights

(cash aid).

■■ I refuse to assign medical support rights (cash

aid and Medi-Cal).

YOUR RIGHT TO CLAIM GOOD CAUSE

Reasons for Claiming Good Cause:

• Cooperation would increase the risk of physical, sexual,

or emotional harm to the child(ren).

• Cooperation would increase the risk of domestic abuse

for the parent or caretaker relative.

• The child(ren) was conceived due to incest or rape.

• Court proceedings are going on for the adoption of the

child(ren).

• You are working with an adoption agency to help you

decide whether to keep or place the child(ren) for

adoption.

• You are cooperating in good faith but are not able to

identify or help locate the noncustodial parent.

• You have other credible reasons why cooperation would

not be in the best interest of the child(ren).

How to Claim Good Cause:

• If you want to claim good cause, you must tell your

worker. You can do this whenever you believe you have

good cause not to cooperate.

• You must also complete and sign the Good Cause Claim

form which your worker will give you.

• If you claim good cause, you must:

Give the county proof that you have good cause for

refusing to cooperate.

Give the proof to the county within 20 days of

claiming good cause. The county will give you more

time if it determines that you need more than

20 days to get your proof.

• If you are claiming good cause and it is not possible for

you to get proof, tell the worker.

The Role of the County:

• The county reviews your Good Cause Claim and the

proof you provide and decides whether you have

good cause.

• The county investigates your facts.

• The county will tell you when you need to provide:

more proof to support your good cause claim, and/or

additional facts so that it will not be necessary to

contact the noncustodial parent or alleged father.

What Is Acceptable Evidence to Claim Good Cause for

Not Cooperating?

• Birth certificates, medical/mental health, rape crisis,

domestic violence program, or police/sheriff records that

show that the child(ren) was conceived due to incest or

rape.

• Records that show you have asked for help with abuse

toward you and/or the child(ren); or records that show

evidence of abuse. These records can be from

police/sheriff, governmental agency, or court records;

facts from a domestic violence program or a professional

from whom you have asked for help in dealing with

abuse; physical evidence of abuse, or any other

evidence that supports an exemption from the

cooperation rules.

• Court documents or other records that show that a legal

adoption is pending in court.

• A written statement from an adoption agency confirming

that you are being helped to decide whether to keep or

place your child(ren) up for adoption.

• Credible sworn statements under penalty of perjury about

the history of abuse or the increased risk of abuse, from

either you or other people who know about the reasons

for your good cause claim for not cooperating.

The Role of the Local Child Support Agency (LCSA):

• If you request a hearing on the issue of good cause, the

LCSA may take part in that hearing.

• The LCSA may try to establish paternity or collect child

support if:

Establishing paternity or collecting child support will

not increase risk of harm to you or the child(ren).

You do not have good cause for refusing to

cooperate.

• After the county tells the LCSA that an applicant/recipient

has claimed to be exempt from the cooperation rules, the

LCSA will not pursue child support enforcement

activities unless the applicant/recipient asks for these

actions to begin or to begin again.

CW 2.1 NOTICE AND AGREEMENT (8/04) REQUIRED FORM - SUBSTITUTE PERMITTED

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