STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES
CREDIT REPORTING DISPUTE CLAIM
DCSS 0675 (08/18/2019)
Section I: Personal Information
First Name
Middle Name
Last Name
Previous First Name Previous Middle Name
Previous Last Name
Physical Address
(number and street) City State Zip Code
Mailing Address
(if different from above) City State Zip Code
Home Phone Number Cell Phone Number Work Phone Number
CSE Case Number Date of Birth
Section II: Employment Information
Occupation
Employer
Employer's Phone Number
Employer's Address (number and street)
City
State
Zip Code
Employment Status
Employed Unemployed Retired Disabled Other (please explain)
Section III: Reason for Dispute
For additional comments, use the back of this form or attach additional sheets.
Signature Date
Please attach a copy of the credit report in question, containing the complete account number, plus any
documents that support your claim. Return this form to your local child support agency for processing.
