■■
TO LCSA REPRESENTATIVE
FROM CWD REPRESENTATIVE CW # PHONE
A. This case is referred to you because:
Action is necessary to obtain:
financial support
medical support
paternity
Recipient is receiving direct support payments. Action needed to
transfer payments to county.
Good Cause has been (see CW 51 attached):
claimed
granted
denied
Other (see comments)
B. The following information applies to this case:
CA 2.1(Q) Questionnaire is attached.
Noncustodial parent has health insurance coverage. A copy of the
DHS 6155 is attached.
Medi-Cal eligibility has not been determined.
Previously sanctioned/penalized; now agrees to cooperate/assign
support rights.
Child no longer resides with recipient.
Medi-Cal Only
CS 909, Declaration of Paternity, is attached.
Other (see comments)
Lamb Case (minor parent not eligible as a dependent child: Family
Code 4000)
C. Applicant/recipient has not agreed to:
Assign:
financial support rights
medical support rights
Cooperate in:
obtaining financial support
obtaining medical support and/or
establishing paternity
Forward support payments.
D. Penalty/Sanction
Penalty has been applied due to non-cooperation.
Sanction has been applied for refusal to assign rights.
Applicant/recipient has cooperated with the law.
Applicant/recipient has not cooperated with the law:
Did not appear and/or provide verbal, written or documentary
information
Rescheduled appointment on
kept
failed
Refuses to appear as a witness at court or other hearing
Refuses to transmit child support payment(s) received directly
from the noncustodial parent
Other (see comments)
This is a notice of renewed cooperation.
Paternity
has
has not been established.
Support order established.
CS 909, Declaration of Paternity, is attached.
Other (see comments)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REFERRAL TO LOCAL CHILD SUPPORT AGENCY (LCSA)
(Complete one form for each Noncustodial Parent or Alleged Father)
TO CWD REPRESENTATIVE CW #
FROM LCSA REPRESENTATIVE PHONE
CASE NAME AID TYPE/CASE NUMBER
DATE OF REFERRAL
APPLICANT/RECIPIENT NAME (LAST, FIRST, MIDDLE) RELATIONSHIP TO CHILD(REN)
MINOR PARENT’S NAME (IF DIFFERENT FROM APPLICANT/RECIPIENT)
E. TYPE OF APPLICATION
NEW
REAPPLICATION
ADD A CHILD
ICT
RENEWAL
NONCUSTODIAL PARENT’S OR ALLEGED FATHER’S NAME CHILD SUPPORT FILE NUMBER
CHILD'S NAME DATE OF BIRTH
MFG RULE APPLIES
CHILD'S NAME DATE OF BIRTH
MFG RULE APPLIES
CHILD'S NAME DATE OF BIRTH
MFG RULE APPLIES
CHILD'S NAME DATE OF BIRTH
MFG RULE APPLIES
F.
APPLICANT PREVIOUSLY RECEIVED AID
SPECIFY
CASH AID
MEDI-CAL ONLY
TMC
PLACE (CITY, COUNTY, STATE) DATE LAST RECEIVED
G.
INTER-COUNTY TRANSFER/INTERSTATE TRANSFER
FROM (COUNTY/STATE) PRIOR COUNTY'S CHILD SUPPORT
FILE NUMBER (IF KNOWN)
H.
CASH AID
PPROVAL D
ONGOING CASH AID AMOUNT
$
DISCONTINUANCE DATE
REASON/CODE FOR DISCONTINUANCE
REASON FOR DISCONTINUANCE
CW 371 (7/01) (FORMERLY CA 371) REQUIRED FORM - SUBSTITUTES PERMITTED
Comments:
I.
MEDI-CAL ONLY
DATE MEDI-CAL BEGINS/CONTINUES DATE DISCONTINUED
