STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES
REQUEST FOR SUPPORT SERVICES
DCSS 0055 (10/20/2019)
CSE Case Number:
INSTRUCTIONS: Read carefully before signing below. Your signature is required in order for us to
open a case for you.
Beginning October 1, 2020, pursuant to the Bipartisan Budget Act of 2018, section 53117 of Public Law
115-123 which amended the provisions of the Federal Deficit Reduction Act of 2005, the Department of Child
Support Services may assess a $35 Annual Service Fee for each case that has never received public
assistance. This fee will be assessed every year on October 1st for each case in which at least $550 has
been disbursed to the family in the prior Federal Fiscal Year (October 1st - September 30th). The fee will be
automatically deducted from the next payment(s) issued to the custodial party after October 1st until the fee
has been recovered in full.
I want the local child support agency to help me get a child support order to establish paternity for the
child(ren) or enforce a support order I have.
I understand that I am applying for these services under the Child Support Services Program under Title IV-D
of the Social Security Act.
I will let the child support agency know right away:
When each child marries.
When each child reaches age 18 years and is no longer attending high school, or 19 years,
whichever happens first.
If my home address, mailing address, or telephone number changes.
If my employer, including name, address, and telephone number changes.
If my income changes.
If my status, cost, or availability of health insurance coverage changes.
If any information regarding the whereabouts of the other parent(s) changes.
If the parent(s) moves back in together with the children, or
If there is any change in custody, childcare or visitation.
I am aware that the local child support agency does not represent me, the other parent, or the children who
are the subject of this case.
No attorney-client relationship exists between the local child support agency
and me, the other parent, or the children. No attorney-client relationship will arise if the local child support
agency provides the support services I have requested.
I declare under penalty of perjury that I have read, understand, and agree to all of the terms
specified above.
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