Fillable DECLARATION OF SUPPORT PAYMENT HISTORY (California)

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DECLARATION OF SUPPORT PAYMENT HISTORY (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES
DECLARATION OF SUPPORT PAYMENT HISTORY
DCSS 0569 (06/17/2018)
INSTRUCTIONS FOR COMPLETING THE DECLARATION
OF SUPPORT PAYMENT HISTORY
On the back of this page is the Declaration of the Support Payment History for your case. Please
provide the amount of support that was ordered by the court and the amount that was paid for each
month. These figures will help determine the amount of the past due support owed, if any.
Within the boxes on the bottom half of the page, please complete the:
• "Amount Ordered" column for each year
• Fill in the amount of support that was ordered by the court each month since your
order began. If there has been a change in your order, make sure each month reflects
the correct amount of support due.
• "Amount Paid" column for each year
• Fill in the dollar amount of support paid in that month. If more than one payment was
made in a given month, put the total dollar amount of support paid. Put the dollar
amount next to the month in which the payment was actually paid, and not the
month the payments were intended to cover. If needed, you may attach more
sheets.
Within the boxes on the bottom half on the page, only if it applies to your case, please complete
the:
• “Incarceration/Institutionalization History"
• Fill in the details of any time periods during which the other parent of your child was
involuntarily confined in a state prison, county jail, juvenile facility, mental health
facility, or other facility. If needed, you may attach additional sheets.
Please complete a separate page(s) for child support, spousal support, family support, medical
support, unreimbursed medical expenses, and other types of support not listed. DO NOT combine
child support and spousal support unless your court order combines the two support
payments into a "family" support order.
Be aware that this Declaration is not confidential and may be given to the other parent or party in
your case for review. If there is a disagreement regarding the payment history, the parties may be
required to present proof of payments, for example, cancelled checks, or receipts.
If you have questions and/or need assistance with child support forms, you can get free help from
your local court's Family Law Facilitator Office. Information for the Family Law Facilitator can be
found at the California Courts website at http://www.courts.ca.gov/selfhelp-facilitators.htm.
Page 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES
DECLARATION OF SUPPORT PAYMENT HISTORY
DCSS 0569 (06/17/2018)
Person completing this form (name):
I am the: Custodial Party
Noncustodial Parent
Support Payment History for (check one):
Child Spousal Family
Unreimbursed medical expenses Medical
Other (specify):
YEAR YEAR YEAR
AMOUNT
ORDERED
AMOUNT
PAID
AMOUNT
ORDERED
AMOUNT
PAID
AMOUNT
ORDERED
AMOUNT
PAID
January
February
March
April
May
June
July
August
September
October
November
December
Incarceration/Institutionalization History
BEGIN DATE
(MM/DD/YYYY)
RELEASE DATE
(MM/DD/YYYY)
FACILITY/INSTITUTION
NAME AND LOCATION
OTHER DETAILS, SUCH AS CHARGING
OFFENSE(S), CONVICTION(S),
VICTIM NAME(S), COURT WHERE
SENTENCED, ETC.
I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct. I am aware that this may be provided to the other parent for their
verification and that either party may be required to provide documentation.
Signature: Date: CSE Case Number:
Page 2 of 2
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DECLARATION OF SUPPORT PAYMENT HISTORY (California)

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Completed 14 February 2021

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