ARTICLE 4

 

                                                             SECTION 18

 


                             MEDICAL SUPPORT ENFORCEMENT PROGRAM

 

1.        GENERAL

 

Title IV-D of the Social Security Act established the child and spousal support enforcement program.  Legislative changes in the Federal Deficit Reduction Act of 1989, the Consolidated Omnibus Budget Reconciliation Act of 1985, and the Omnibus Budget Reconciliation Act of 1987, required that Medi-Cal applicants and beneficiaries must cooperate in medical support enforcement as a condition of eligibility.  Effective July 1, 1993, applicants and beneficiaries requesting Medi-Cal for a child born out of wedlock (see item 11 for Voluntary Declaration of Paternity) or with an absent parent, must cooperate by assigning to the State medical support rights and payments, establishing paternity and providing information on the absent parent or any third party liable for medical support.

 

 

MEM 50185

 

Three agencies are involved in San Diego County's Child/Medical Support Enforcement Program.  The three agencies are (1) the Health and Human Services Agency (HHSA), (2) the Department of Child Support Services (DCSS) and (3) the Department of Revenue and Recovery (R&R).  The duties and responsibilities of each agency are as follows:

 

A.       Health and Human Services Agency

 

Informs each Medi-Cal applicant or recipient of their support rights and responsibilities via Form CS 196; and

 

Provides and explains the necessary forms to the client and reviews completed forms; and

 

Refers the client to the DCSS for child support action.

 

 


B.       Department of Child Support Services

 

Locates absent parents; and

 

Establishes, through court action, paternity and the absent parents support obligation; and

 

Initiates, through court action, child/spousal support collection activities; and

 

Prosecutes absent parents for non-payment of child/spousal support obligations.

 

 

 

 

 


C.       Department of Revenue and Recovery

 

Establishes the account for collection of a support obligation; and

 

Maintains the records for collection of the support obligations.

 

 

2.        CONDITION OF ELIGIBILITY

 

The worker must inform a Medi-Cal applicant/beneficiary requesting Medi-Cal for a child born out of wedlock or with an absent parent that, as a condition of eligibility, they must:

 

A.       Assign to the State the applicant's or beneficiary's rights to any medical support and payments;

 

B.       Cooperate in obtaining medical support and payments;

 

C.       Cooperate in establishing paternity for a child born out of wedlock for whom aid is requested;

 

D.       Cooperate in identifying and locating the absent parent; and

 

E.       Provide information about possible entitlement to medical support and payments available through any third party.

 

An applicant or beneficiary who refuses to cooperate without good cause with any of the above will be determined ineligible for Medi-Cal.  This will not affect the child(ren)'s regular Medi-Cal eligibility.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEM 50379


3.        COOPERATION INCLUDES THE FOLLOWING:

 

A.       Provide the name of the alleged or absent parent, along with other known information, such as address, Social Security number, telephone number, place of employment, school, or names and addresses of relatives or associates;

 

B.       Appear at interviews, hearings, and legal proceedings when adequate notice of the interview is provided. Medi-Cal applicants/recipients must have good cause for failure to appear;

 

C.       If paternity is an issue, submit to genetic tests, including tests of child, if necessary;

 

D.       Provide any additional information reasonably obtainable by the applicant or recipient necessary to establish paternity or to establish, modify, or enforce a child support order;

 

E.       An applicant/recipient shall not be required to sign a voluntary declaration as a condition of cooperation.

 

MEM Ltr # 200

4.        MEDICAL SUPPORT REFERRAL NOT REQUIRED

 

A Medical Support Referral is not required for the following:

 

A.       Children over 18,

 

B.       Undocumented children (OBRA),

 

C.       Pregnant women and their other eligible child(ren) until the end of the 60-day postpartum period,

 

D.       Applicants for minor consent services,

 

E.       Children in Foster Care or Adoptive Aid Programs,

 

 

F.       Children removed from parental custody by court order,

 

G.       Applications for retroactive Medi-Cal only,

 

SDHS

clarification

MEM Proc.

23D

H.       Situations where the absent parent is incarcerated or institutionalized,

 

I.         Situations where the absent parent is already providing health insurance (a referral is needed if the health insurance is later terminated) unless paternity must be established. All forms must be completed on other health care coverage and kept in the file, and a copy of the DHS 6155 must be sent to DHS. (A referral is needed if the health insurance is later terminated.)

MEM Ltr # 200

J.        Adult Children - Adult children are children between the ages of 14 to 18 years who are not living in the home of a parent or caretaker relative and who do not have a parent, caretaker relative, or legal guardian handling any of their financial affairs.  The parents do not claim the children as dependents in order to receive a tax credit or deduction for state or federal income tax purposes.

 

K.       Transitional Medi-Cal or Four-Month Continuing Medi-Cal cases,

 

L.        Children in Healthy Families Program.

ACWDL

95-69

 

 

 

 


MEM Ltr # 200

 

MEM Ltr # 202

               

If a Medical Support Referral was completed at intake, no referral is required at redetermination.

 


5.        REFERRAL FORMS

 

When an individual applies for Medi-Cal on behalf of a child who is born out of wedlock or not residing with one or both parents, the HHSA must take certain actions related to medical support.  These actions must also be taken when a Medi-Cal application is filed on behalf of a child whose parents are unmarried but living together and paternity has not been established.

 

A.       Forms

 

HHSA must request that Medi-Cal applicants or recipients complete the following forms to meet the responsibilities of medical support enforcement.

 

 

MEM 50185


1)      07-72 HHSA - Referral to DCSS

 

                        The 07-72 is a shelf stock form and is also printed from the 2700 laser printer.  Two copies of the 07-72 are printed at intake.  The worker uses the 07-72 to refer a case to DCSS for medical support enforcement activi­ties.  The 07-72 is also used for communication between HHSA and the DCSS after the referral has been made.  Either the ET or DCSS may initiate the form whenever new or additional information is to be shared.

 

 

                        When the case is referred to DCSS, the Form 07-72 is distributed as follows:

 

a)        AIS Cases

 

                                (1)    When the case is granted or denied, two 07-72 forms will be printed automatically from the 2700 laser printer indicating what case action was taken.  One 07-72 will be forwarded along with the original CW 2.1 Notice & Agreement and the CA 2.1 (Q) to DCSS.

 

                                (2)    One 07-72 and a copy of the CW 2.1 Notice & Agreement will be filed in the case folder under the ROR/UAM tab.

 

                                (3)    A copy of the CW 2.1 Notice & Agreement is given to the client.

 

b)        Manual Cases

 

                                (1)    When the case is granted or denied, the worker will complete the 07-72 in duplicate, indicating the action taken.  Forward the original 07-72 to DCSS along with original CW 2.1 Notice & Agreement and the CA 2.1 (Q).

 

                                (2)    A copy of the 07-72 and CW 2.1 Notice & Agreement will be filed under the ROR/UAM tab.

 


 


                                (3)    A copy of the CW 2.1 Notice & Agreement will be given to the client.

 

2)      CW 2.1 - Child Support Notice and Agreement

 

                        The CW 2.1 Notice & Agreement is to be used with the CA 2.1 (Q), Support Questionnaire.  The Notice & Agreement explains the assignment of the support, the benefits of Child Support enforcement, coopera­tion requirements, the Attestation Statement, and the right to claim good cause (CA 51). Additional explanation of how to claim good cause is provided on the reverse side of the form.

 

                        The CW 2.1 Notice & Agreement is to be completed in triplicate by all appli­cants or recipients in absent parent and paternity cases.  The original is sent to DCSS, one copy is filed in the case and one copy is given to the client.

 

                        One CW 2.1 Notice & Agreement is required for each absent parent.  In cases with more than one absent parent, the worker will modify the Agreement Section of the form by notating the name of each absent parent on each CW 2.1 Notice & Agreement.

 

 

 

 

 

3)      CA 2.1 (Q), Support Questionnaire

 

                        The CA 2.1 (Q), Support Questionnaire is completed and signed by the client in all absent parent and paternity cases.  It is completed on each absent parent or when the unmarried father is in the home and aid is requested for the common child(ren). Once the form is completed, the form is forwarded to DCSS with the 07-72. The worker will retain in the case file a copy of the 07-72 and the CA 2.1 (Q).

 

 

                        The applicant/recipient has the responsibility for completing the CA 2.1 (Q).  The worker's responsibility is to ensure that:

 

a)        The shaded data elements are completed by the applicant/recipient;

 

b)        The form is signed and dated; and

 

c)        A copy of the form is transmitted to the DCSS no later than two work days following authorization of aid.

 

                        NOTE:      The CA 2.1 (Q) is not completed by the client if a good cause determination is pending (CA 51).

 

 

4)      CA 51 - Good Cause Claim and Determination Transmittal

 

                        Form CA 51 is completed when the client claims good cause for refusal to cooperate with DCSS in child support matters.  See 7. and 8. below for definition of Good Cause and procedures.

 

5)      CDS 284 - Child Support Data Exchange Form

 

                        The CDS 284 is a CDS generated form used by HHSA to communicate with R&R when a CalWORKs case is opened or reopened.  This form provides R&R with information matching the HHSA case with the R&R case.

 

 

6)      CDS 841 - Child Support History (Refer to Appendix A1)

 

                        The CDS 841 is sent to workers each month and provides notification of the amount of child support received by Fiscal Division.

 


6.        REVENUE AND RECOVERY ACCOUNT NUMBERS

 

In San Diego County, the DCSS Account Number shown on the J Line of the CDS document is actually the Revenue and Recovery Medical Support Collection Account Number for the absent parent.  The entry known as the DCSS Account Number consists of a letter D, a dash, and the seven digits of the Revenue and Recovery A.R.T.A.S. (Accounts Receivable and Trust Accounting System) number.

 

A.       Use of the R&R Account Numbers

 

In cases with two absent parents where there are two R&R Account Numbers for the same child, a letter "M" for Multiple Payees must be entered in the space immediately following the R&R Account Number of either parent. The letter "M" indicates to R&R that there is more than one absent parent and/or Account Number for the same child, and enables R&R to cross reference their files when there are changes related to child support activities.  The DCSS case number is not listed on the SS system.

 

 



The R&R Account Number will always take precedence to entry of Railroad Retirement, Social Security Claim No., or Alien Registration Number.  The R&R Account Number is not to be confused with the six digit number used by DCSS to identify their files.

 

R&R Account Numbers are added, changed, corrected, or deleted by EDP upon communications from Revenue and Recovery.  Workers will not generally take any action on these numbers except when moving a child from one case to another case.  For instructions on how to enter the R&R number reference IM-EDP manual 1-30.

 

 

B.       Automatic Generation of Form CDS 284

 

When an R&R Account Number is entered on the computer document, a form CDS 284 will be automatically generated to R&R.  This form provides R&R with information matching the welfare case with each R&R Account Number and includes case identification data, eligibility status/dates, and person with same R&R Account Number.

 

 

When a R&R Account Number exist and it becomes necessary to transmit an alien registration number (A+8 digit number) for SAVE transaction, the "A" must be changed to a "V" with the 8 digit alien number and entered on the J line, Box 54 of the 279 LMB document.  This action will prevent the R&R Account Number from being overlayed.  The alien registration number will not print back on the turnaround document.  The CDS 284 will continue to be automatically generated to R&R.  (Refer to CDS Code and Message Handbook 1-167.)

 

 


7.        REFERRAL PROCEDURES

 

A.       Procedures Prior to Intake

 

1)      Provide Form CS 196, Child Support Enforcement Notice, to all Medi-Cal applicants requesting aid for a child born out of wedlock or with an absent parent.

 

2)      Explain to the applicant that as a condition of eligibility they are required to:

 

a)        Assign to the State rights to any medical support and payments;

 

b)        Cooperate in obtaining medical support and payments;

 

c)        Cooperate in establishing paternity for a child born out of wedlock;

 

d)        Cooperate in identifying and locating the absent parent;

 

e)        Provide information about possible entitlement to medical support and payments available through any third party; and

 



f)         Appear at DCSS when requested or as a witness in court; or

 

g)        Provide documentation to substantiate a claim of good cause for refusing to cooperate.

 

3)      Provide the client a CW 2.1 Notice & Agreement and CA 2.1 Questionnaire for each absent parent or unmarried father in the home.

 

4)      Instruct the client to have the CW 2.1 Notice & Agreement and CA 2.1 Questionnaire completed, but not signed, by the time of the scheduled Intake interview.

 

 

B.       Intake Procedures

 

1)      If the applicant does not claim good cause, has not agreed to assign his/her rights to medical support and does not cooperate with DCSS in paternity establishment and identification of medical support, Medi-Cal will be denied for the custodial parent only and the children will be referred for medical support enforcement. Refer to MPG 4-18-9 for procedures when the applicant does not agree to assign his/her rights to medical support.

 

2)      If the applicant does not claim good cause, has agreed to assign his/her rights to medical support but does not cooperate with DCSS in paternity establishment and identification of medical support, Medi-Cal will be denied for the custodial parent only and the children will be referred for medical support enforcement. The worker will complete the 07-72, attach a copy of page 1 of the MC 210 or MC 210S-C (whichever lists the child’s name, DOB and parents), as well as a copy of the signature page of the MC 210 and forward to DCSS.

 

3)      If the applicant has agreed to assign his/her rights to medical support, but has indicated on the CW 2.1 Notice & Agreement intent to claim good cause for refusal to cooperate with the DCSS obtain the applicant’s signature and the reason for the claim on form CA 51. Proceed with the good cause determination using the criteria and procedures in MPG 4-18-7,8. Medi-Cal benefits will be granted while the good cause claim is processed if all other eligibility factors are met. Provide the applicant with a copy of the CW 2.1 Notice & Agreement.

 

 

 


ACWDL

98-22

4)      If the applicant has agreed to assign his/her rights to medical support and agreed to cooperate with medical support enforcement, the worker will have the applicant sign the CW 2.1 Notice & Agreement and complete the CA 2.1 Q. It is presumed the applicant is cooperative unless the ET receives information from DCSS stating otherwise.

 

·         Provide the applicant with a copy of the CW 2.1 Notice & Agreement.

·         File a copy of the 07-72 and the CW 2.1 Notice & Agreement in the case under the ROR/UAM tab.

·         Note on the 07-72 if the applicant is planning to place his/her child for adoption.

 

 

 

 


ACWDL

98-22

5)      Information that is not available at the time of initial referral will be sent to DCSS by the worker on a follow-up form 07-72. The case is not to be held in Intake solely for the purpose of obtaining information not available at the time of initial referral. Intake has met their responsibility once they have completed the activities in B1 through B4 above. Refer to Appendix D, Cooperation Determinations and Good Cause Claims.

 

C.       Referral Process

 

There is no requirement for a referral to DCSS at annual redetermination. Any changes or information updates on a granted Medi-Cal case are to be reported to DCSS using form 07-72. The following co-located procedures are for intake only:

 

1)      Co-Located Sites

 

DCSS staff is co-located in FRCs that do Medi-Cal intake. In FRCs that have DCSS co-located staff, intake ETs will provide the on-site Child Support Officer (CSO) with the child support referral after the initial face-to-face intake interview is completed. When the intake interview is completed, the ET will deliver the CW2.1 and CW2.1Q to the CSO, and instruct the applicant to wait to be seen by the CSO. Upon granting, the 07-72 is also given to the on-site CSO.

 

Note: Applicants are to be encouraged to attend the on-site interview with a CSO. If they cannot, the referral is to be sent to DCSS via the batch process whereby the original CW2.1 and CW2.1Q are forwarded to DCSS at mail stop C‑77, ATTN: Intake.

 

If the on-site CSO is going to be absent, he/she is to notify the FRC administration in advance, or at the latest, the morning of the absence so that intake staff can be advised. For the duration of the absence, intake staff will revert to a batch process for the child support referrals.

 

 

 

County

Policy


If the CSO is in the FRC, but is unavailable, he/she will place an out card at his/her workstation to notify intake staff that they are not available. In this situation, the ET staff shall leave the referral, along with the applicant’s phone number, if available, for the CSO in a specified box or location. The CSO will attempt to contact the applicant for a phone interview. The ET shall advise the applicant that the CSO may call for an interview.

 

County

Policy

2)      Phone Referrals

 

At FRC sites where DCSS is not co-located, phone referral procedures have been developed for the child support process as follows:

 

·         The intake worker will provide a Phone Referral Form to the applicant after the initial intake interview

·         The intake worker will fax a copy of the CW2.1 and CW2.1Q to DCSS immediately after the initial intake interview. This information must be received by DCSS before a phone interview can be conducted. The DCSS fax number is (619) 236-4405.

·         The original CW2.1 and CW2.1Q are to be forwarded to DCSS at mail stop C-77, ATTN: HHSO.

 

 

 

D.       Granted Procedures

 

1)      The worker shall refer to DCSS via Form 07-72 when:

 

a)        Deprivation changes to absence; or

 

b)        A newborn is added to the MFBU. (A new CW 2.1 Notice & Agreement and Questionnaire are required on the absent/other unmarried parent); or

 

 


c)        A child enters the home and is added to the MFBU.  (A CW 2.1 Notice & Agreement and a Questionnaire are required on the absent parent/other unmarried parent); or

 

d)        An absent parent returns to the home (even if this results in case discontinuance); or

 

e)        Any new information is available on the whereabouts of the absent parent; or

 

f)         The recipient children ceases living with the applicant parent or caretaker relative; or

 

g)        The recipient receives medical support not forwarded to the County; including medical support benefits which are sent to the custodial parent on behalf of the child(ren); or

 

h)        The client responds to the noncooperation notice; or

 

i)         Client obtains a divorce - send copy of court order if available; or

 

j)         Child is adopted or relinquished; or

 

k)        Medi-Cal is discontinued; or

 

 

l)         A face-to-face interview is not required for the client to complete the referral forms.

 

2)      Closed Cases

 

                        When a Medi-Cal case closes, DCSS and Revenue & Recovery must continue child support activities requested by the client, until the client requests R&R to terminate.

 

 

3)      Reapplication for Medi-Cal

 

                        Regardless of whether the DCSS case/R&R accounts are active or closed, when the client reapplies for Medi-Cal, a referral to DCSS must be completed, even if there is documentation in the case file supporting a previous good cause or rejection determi­nation by DCSS. The DCSS staff will then re-evaluate each referral and decide whether the previous determination in their files is still valid, or whether to proceed with enforcement of medical support.

 

 


4)      Attestation Statement

 

                        An Attestation Statement (CS 870) gives a caretaker relative an opportunity to attest, under penalty or perjury, that he/she has provided complete and accurate information about an absent parent.  DCSS has the responsi­bility of offering the caretaker relative the opportunity to sign the Attestation Statement when making a non-cooperation evaluation.

 

                        If a caretaker relative, who has been determined noncooperative by DCSS requests to sign an Attestation Statement, the worker will:

 

a)        Have the caretaker relative sign a new CW 2.1 Notice & Agreement and CA 2.1 Questionnaire.

 

b)        Refer the caretaker relative to DCSS with a new 07-72.

 

c)        Attach a copy of the 07-72 initiating the noncooperation to the new 07-72.

 

 

E.       Unmarried Father Residing in the Home - Medi-Cal Requested for Common Child(ren)

 

1)      Intake

 

                        When the unmarried father is in the home and Medi-Cal is requested for the common child(ren), provide the applicant with a CW 2.1 Notice & Agreement, CA 2.1(Q).

 

                        The worker will forward to DCSS, a copy of page 1 of the MC 210 or MC 210S-C (which ever lists the child's name, date of birth and parents), a copy of the signature page of the MC 210, the original CW 2.1 Notice & Agreement, CA 2.1(Q) with the 07‑72 referral form. A copy of the CW 2.1 Notice & Agreement and 07-72 will be filed under the ROR/UAM tab of the case file.

 

 

 

 

                        A copy of the CW 2.1 Notice & Agreement will be given to the client.

 

                        When unmarried parents in an intact family complete and sign a Declaration of Paternity in the district office, the Declaration establishes paternity immediately.  The Declaration is a legal document once it is filed with the Office of Vital Records even though the 60-day rescission period has not elapsed.  Therefore, no referral should be made to DCSS for paternity establishment if the Declaration is signed by both parents.

 

 

 

EMC2

#97043

 


                        See item 11 for Voluntary Declaration of Paternity.

 

2)       Granted

 

When an unmarried father is residing in the home and Medi-Cal is requested for the common child(ren), the worker will provide the applicant with forms CA 196.  Have the applicant complete a CW 2.1 Notice & Agreement and CA 2.1 (Q).  The worker will complete a 07-72, attach the original CW 2.1 Notice & Agreement and CA 2.1 (Q) and forward to DCSS.

 

                        File a copy of the 07-72 and CW 2.1 Notice & Agreement under the ROR/UAM tab in the case file.

 

Provide the applicant with a copy of the CW 2.1 Notice & Agreement.

 

                        When unmarried parents in an intact family complete and sign a Declaration of Paternity in the district office, the Declaration establishes paternity immediately.  The Declaration is a legal document once it is filed with the Office of Vital Records even though the 60-day rescission period has not elapsed.  Therefore, no referral should be made to DCSS for paternity establishment if the Declaration is signed by both parents.

 

 

 

 

 

EMC2

#97043

 

 

 

 

 

 

 

 

 

 

 

EMC2

#97043

                        See item 11 for Voluntary Declaration of Paternity.

 

 

8.        GOOD CAUSE

 

The applicant/beneficiary may claim good cause for noncooperation in establishing paternity, medical support payments, or identifying third party liability if he/she feels there is a risk of emotional or physical harm to himself/herself or a child(ren) if a referral is made.  The county must determine if the applicant/beneficiary, in fact, has good cause for failure to cooperate with medical support requirements.

 

If good cause is claimed, Medi-Cal is granted pending the good cause determination if the applicant is otherwise eligible.

 

 

 

 

 

 

 

 

 

MEM Proc.

23E

A.       Good Cause Exists if:

 


1)      Efforts to establish paternity or establish, modify or enforce a support obligation would increase the risk of physical, sexual, or emotional harm to the child for whom support is being sought;

 

2)      Efforts to establish paternity or establish, modify, or enforce a support obligation would increase the risk of abuse the parent or caretaker with whom the child is living;

 

3)      The child for whom support is sought was conceived as a result of incest or rape. A conviction of incest or rape is not necessary for this paragraph to apply;

 

4)      Legal proceedings for the adoption of the child are pending;

 

5)      The applicant/beneficiary is being assisted to resolve the issue of whether to keep or relinquish a child for adoption;

 

6)      The applicant/beneficiary is cooperating in good faith but is not able to identify or assist in locating the alleged father or absent parent;

 

7)      Any other reason that would make efforts to establish paternity or establish, modify, or enforce a support obligation contrary to the interest of the child.

 

 

MEM Ltr # 200

 

B.       The Applicant or Beneficiary Must:

 

1)      Provide a written statement specifying the circumstances that the individual believes provides sufficient good cause for not cooperating and provide sufficient information such as the absent parent's name and address to permit an investigation.

 

2)      Provide evidence that supports the claim of good cause within 20 days.

 

3)      Make a request, if additional time is needed because of difficulty in obtaining the evidence.  A reasonable additional period of time will be allowed with approval from a supervisor.  The worker will document the request and approval/denial in the case file.

 

 


C.       Evidence Supporting a Claim of Good Cause Includes:

 

1)      Police, governmental agency, or court records, documentation from a domestic violence program, or a legal, clerical, medical, mental health, or other professional from whom the applicant or recipient has sought assistance in dealing with abuse, physical evidence of abuse, or any other evidence that supports the claim of good cause;

2)      Statements under penalty of perjury from individuals, including the applicant/beneficiary with knowledge of the circumstances surrounding the good cause claim;

 

3)      Birth certificates or medical, mental health, rape crisis, domestic violence program, or law enforcement records that indicate that the child was conceived as the result of incest or rape;

 

4)      Court documents or other records that indicate legal proceedings for adoption are pending;

 

5)      A written statement from a public or licensed private adoption agency that the applicant/beneficiary is being assisted by the agency to resolve the issue of whether to keep the child or relinquish the child to adoption.

 

 


MEM Ltr # 200

 

 

 

 

MEM Ltr # 200


 

D.       Applicant/Beneficiary Requests Assistance

 

 

1)      If requested, the worker will advise the applicant or beneficiary of how to obtain the necessary evidence and/or make a reasonable attempt to obtain the specific information if the applicant or beneficiary is unable to without assistance.

 

 

2)      Contact with the absent parent or putative father will not be made unless necessary to establish a good cause claim.  The applicant or beneficiary must be informed that the absent parent or putative father may be contacted unless they present evidence to support the claim of good cause, withdraw the application or request discontinuance.

 

3)      If a claim is based on the individual's anticipation of physical harm and evidence is not submitted, the worker can make reasonable efforts to examine, review and evaluate the good cause claim when:

 

a)        The claim is credible without corroborative evidence, and

 

b)        Evidence is not available.

 

                        Good cause can be found if the client's statement and the investigation document that the individual has good cause for refusing to cooperate.

 

 


9.        GOOD CAUSE DETERMINATION PROCESS (Form CA 51)

 

The good cause determination process applies to all cases where the applicant/recipient claims good cause for refusing to cooperate in establishing paternity and/or obtaining support.  Once good cause is established, it continues unless the parent/caretaker parent rescinds the claim for good cause and is able to cooperate with medical support enforcement.  Review at redetermination to see if circumstances have changed; it is not necessary to process another claim for good cause.  No statistical reporting will be required from workers on good cause determinations.

A.       Good Cause (CA 51)

 

1)      Client Responsibility

 

                        If the client chooses to claim good cause for refusing to cooperate, a Form CA 51 must be completed.  Request the client to indicate, by checking the appropriate box, the reason for the claim.  Obtain the client's signature.  Enter the case name and number, names and birthdates of the children and the absent parent's name in the County-Use-only section (upper right-hand corner).

 

a)        Instruct the client to provide documentation of the good cause claim (per instructions on the reverse of the CW 2.1 Notice & Agreement) within 20 days.

 

 

 

 

 

SDHS

Letter Dated

9/24/93


 

b)        Proceed to grant the case with the parent/caretaker relative in the MFBU if otherwise eligible.

 

 

c)        If a client is unable to obtain all the necessary documen­tation for the Good Cause Determination during the time the case is assigned to Intake, the worker is to complete the procedure to the fullest extent possible, and indicate in the narrative that the Good Cause Determination is pending.

 

 

d)        A client's statement is required to specify the circum­stances the client believes provide sufficient reason to claim good cause for not cooperating further.  Attach the statement to the CA 51.

 

e)        The incomplete Form CA 51 is to be filed on the top, right-hand side of the case file as a reminder to the granted worker to complete the determination.

 

f)         After the rest of the intake procedure is completed, the case can be transferred to granted.

 

 

2)      HHSA Responsibility

 

                        If the client requests more information about child support activities prior to claiming good cause, he/she may be referred to DCSS for an information only interview.  A referral will be made by sending a gram to DCSS.

 

                        The good cause determination must be completed in 45 days.  This time standard may be extended in exceptional cases when the client requests additional time because of difficulty in obtaining the evidence.  The worker can allow a reasonable additional period of time with the approval of a supervisor.

                        The worker should have the client submit the request in writing for approval or denial by a supervisor.  The worker will file the written request under the ROR/UAM tab.  Justification for additional time must be fully documented in the case file.

 

 


a)        When all available documentation is obtained, the worker will complete the "Evidence Provided" section of the Form CA 51 on all cases.

 

                                If a good cause claim is based on physical harm to either child or parent, the worker will:

 

                                (1)    Identify/record the corroborative evidence obtained in this section; and/or

 

                                (2)    If sufficient corroborative evidence is available check off "No Investigation."  (Acceptable evidence is identified on the back of the CW 2.1 Notice & Agreement.)

 

 

b)        The worker will attach the available documentation to the Form CA 51 and forward it to the supervisor.  The supervisor will review and then forward the CA 51 to the FRC Assistant Manager for the "Final Determination."

 

c)        The ADM will review the CA 51 and available documentation and complete the "Final Determination" section of the CA 51. Information related to the good cause claim may be requested from the DCSS, however, it is not a requirement to request an independent evaluation of the good cause claim from the DCSS. The FRC assistant manager will also check off “May” or “May not” proceed without the applicant or recipient’s participation (Ref. MEM 50771.5).

 

d)        The Assistant Manager will sign the CA 51 and return the entire packet to the worker.

 

 

 


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B.       Good Cause Claim, Withdrawn/Cancelled

 

If the client chooses to withdraw or cancel a good cause claim, the Medi-Cal application is withdrawn, or aid is discontinued before the final determination is completed, the worker will:

 

1)      Enter the client's action in the "Final Determination" section, complete the "Withdrawal" item in the "Statistical Summary" section, and forward the CA 51 to the ADM for signature.

 

2)      Send one copy of the signed CA 51 to DCSS with a Form 07-72 and retain the original in the case file.

 

 

C.       Good Cause Exists

 

When it is determined that good cause exists, the worker will:

 

1)      Complete and send a Notice of Action to the client, informing him/her of the determination.

 

2)      Tic for review of good cause at annual renewal.

 

3)      Send one copy of the signed CA 51 to DCSS with a Form 07-72 and retain the original in the case file.

 

4)      Refer the applicant to the appropriate community, legal, medical or support services.

 

 

 

 

 

 

 

 

 

 

 

 

 

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D.       Good Cause Does Not Exists

 

When it is determined that good cause does not exist, the worker will:

 

 


1)      Complete and send a Notice of Action to the client informing him/her of the denial of the good cause claim.

 

2)      Inform the applicant that there will be a referral to the DCSS and the applicant will be given the opportunity to cooperate.  The applicant also has the option to withdraw the application for aid or to have the case closed.  The applicant is to be informed that continued refusal to cooperate will result in ineligibility of his/her Medi-Cal, however, the children’s Medi-Cal will continue.

 

3)      Send one copy of the signed CA 51 with attachments, Form 07-72 and a copy of the CW 2.1 Notice & Agreement and Questionnaire to DCSS for a cooperation determination.

 

4)      Review the cooperation determination from DCSS and verify the evidence that the applicant/custodial parent failed or refused to cooperate without good cause. If this is the case, the applicant will be discontinued from Medi-Cal. This determination does not affect the eligibility of the children. Procedures in MPG 4-18-10 B.3 will be used for applicants determined non-cooperative by DCSS.

 

10.      ASSIGNMENT OF MEDICAL SUPPORT RIGHTS

 

Assignment of Support Rights means that upon receipt of Medi-Cal, a client agrees to transfer all medical support rights to the county.  This means that the County Department of Revenue and Recovery will collect and forward to HHSA Fiscal Division all medical support money as long as recipient remains on Medi-Cal.

 


 

If the parent/relative caretaker does not wish to or refuses to agree to the assignment of medical support rights, he/she must make such refusal in writing on the CW 2.1 Notice & Agreement or provide a separate statement to this effect.  When written refusal is made, the parent/relative caretaker shall be an ineligible member of the MFBU. The worker will still refer the case to DCSS and note on the 07-72 that the client has refused to assign medical support rights.

 

For granted cases, if a client contacts HHSA and indicates his/her refusal to assign medical support, he/she should be requested to make such a statement in writing.  Within timely notice limitations, the non-cooperative parent/relative caretakers shall be determined an ineligible member of the MFBU.  DCSS will continue to pursue the absent parent for the payment of a medical support contribution.  If a contribution is secured it will go directly to Revenue and Recovery.

 


 

11.      COOPERATION REQUIREMENTS

 

A.       Establishing Cooperation

 

A client will be presumed to be cooperative with DCSS when the client completes the required forms and the worker makes a referral to the DCSS.

 

B.       Non-Cooperation

 

1)      DCSS Determination

 

                        When the DCSS indicates to HHSA that a client has not cooperated, and has not established good cause for failure to cooperate, DCSS will notify HHSA using Form 07-72.

 

 

                        HHSA provides the noncooperation information in Section II of the 07-72.  The information supplied by the DCSS is to assist the worker in determining if the client had good cause for not cooperating with the DCSS.

 

 

2)      HHSA Determination

 

                        HHSA shall verify the facts provided by the DCSS, and verify whether the recipient failed to cooperate and whether he/she had good cause for his/her failure.

 

                        DCSS supplies various standardized language on the Form 07‑72 to assist the worker with the cooperation determination.

 

                        DCSS's responses which appear in Section D of Form 07-72 under the heading "Information From District Attorney (DA) To CWD" and the good cause action required on the standardized responses are as follows:

 

a)        Refuses to appear for appointment

 

                                (1)    The worker will wait for five days after the Form 07‑72 is received from DCSS.  The worker will make an effort to contact the client by phone.  If the client does not contact the worker, the worker will send a timely NOA and remove the caretaker from the MFBU.  If the client contacts the worker within this timeframe or prior to discontinuance, a good cause determination must be made by the worker. 

 

b)        Refuses to provide verbal, written or documentary information

 

                                (1)    The worker will follow the guidelines for non-cooperation with Medical Support.

 


3)      Worker Responsibilities

 

                        The worker will follow the procedures outlined below when notice of non-cooperation is received.

 

a)        Contact the client and verify the facts as provided by the DCSS; this contact may be by telephone or in person.

 

b)        Determine whether the recipient failed to cooperate as required or whether he/she had good cause for his/her failure.

 

c)        If the worker determines that the recipient failed to meet the cooperation requirements, the worker will:

 

                                (1)    Take immediate action to remove the parent, or needy caretaker relative, from the MFBU following appro­priate NOA notification.  NO action is to be taken to terminate aid to the needy children.

 

 

                                (2)    Notify the client via a NOA of this action.  The NOA must advise the recipient that his/her Medi-Cal will be restored when he/she cooperates with DCSS.

 


 

                                (3)    Send a Form 07-72 notifying DCSS of the action taken on the notice of non-cooperation.  (Send to the CSO who signed the non-coop 07-72 at MS C-77 or to CSO in your office if it was initiated by a CSO in district).

 

                                (4)    If the recipient responds to the NOA and wishes to cooperate, the worker will immediately re-refer the recipient to the DCSS.  Upon notification from the DCSS (via the Form 07-72), that the recipient has now cooperated, the worker will immediately reinstate aid for that person as of the month cooperation was obtained.

 

 


d)        If the worker determines that the client has cooperated to the fullest extent possible or has good cause for refusing to cooperate, the worker will:

 

                                (1)    Obtain a Form 07-42 Sworn Statement from the client in which the client explains the circumstances surrounding the noncooperation determination by the DCSS or the reasons the client cannot cooperate (documen­tation) or believes he/she cannot cooperate.

 

                                (2)    Prepare a gram to the FRC Assistant Manager which includes:

 

                                        (a)    Basic identifying information such as case name, case number, worker number, and absent parent name.

 

                                        (b)    Description of current case status.

 

                                        (c)    Summary of the reason for DCSS non-cooperation determination.

 

                                        (d)    Summary of the client's explanation for his/her action which resulted in non-cooperation determination.

 

                                        (e)    Describe basis for worker's determination that client is cooperative.

 

                                        (f)     The gram, with a copy of the DCSS's 07-72 and a copy of client's sworn statement (Form 07-42) attached, is submitted to the Assistant District Manager for review.

 


 

4)      FRC Assistant Manager Responsibilities

 

a)        If the FRC Assistant Manager determines that the client is noncooperative, this decision will be noted on the memo and all forms returned to the worker who will immediately take action forth.

 

 

b)        If the FRC Assistant Manager determines that the client is cooperating to his/her fullest ability, this decision will be noted on the memo and forwarded to the worker.  No action is to be taken to delete the parent/relative caretaker from the budget, and the client will be considered cooperative.  A copy of the gram is forwarded to DCSS (send to the DCSS worker who initiated the non-coop).

 


 

12.      VOLUNTARY DECLARATION OF PATERNITY PROGRAM

 

        Effective January 2, 1997, unmarried parents applying for Medi-Cal shall be informed of the availability of the voluntary declaration of paternity, and be given the option of signing the CS 909 to establish paternity:

 

 

A.       If the unmarried parents choose not to sign the declaration of paternity, they must still cooperate with the DCSS in establishing paternity for Medi-Cal eligibility purposes.

 

 


B.       If the parents volunteer, and there is no conflicting information, the form must be signed by both parents and witnessed by the eligibility technician.  Appropriate copies (see CS 909 under Forms below) of the completed declaration are to be sent with other documentation indicated in Item 6D of this section, to DCSS.  A note will be entered on the 07-72 to indicate that the Declaration has been signed and is attached.  DCSS will forward the declaration to the State Office of Vital Records in Sacramento.  After 60 days, the Declaration of Paternity will have the same force and effect of law as a judgment rendered by a court.  No DCSS referral for paternity establishment should be made if the Declaration is signed by both parents.

 

 

 

 

 

 

 

 

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C.       If there are any questions regarding legal issues that are not answered by the brochure (see PUB 244 under Forms below) or information sheet (see CS 910 under Forms below), and the clients choose not to sign the declaration, a referral will be made to DCSS without the Declaration.  If the clients choose to sign the Declaration despite unanswered questions, the signed Declaration will be sent with other documentation to the DCSS, with the questions noted on the 07-72 or on a separate sheet of paper, as appropriate (keep a copy of this sheet of paper with the questions in the case file).  The worker may inform the parents that the signed Declaration may be rescinded by either parent by filing a rescission with the State Office of Vital Records within 60 days of execution or by a judicial proceeding.

 

 


D.       When either parent is a minor, the Declaration of Paternity does not establish paternity until 60 days after the minor parent (or if both parents are minor, then both parents) is (are) emancipated or 60 days after the 18th birthday of the minor parent(s), whichever occurs first.

 


 

Forms

 

CS 909 (1/97) C DECLARATION OF PATERNITY (Appendix B)

 

This is a four-part carbonized (NCR) form that when completed, witnessed and officially filed, is an acknowledgement of paternity.  This form has a blue informational coversheet which contains the heading, IMPORTANT NOTICE TO UNMARRIED PARENTS, and an explanation of the purpose of the form.  The second page contains instructions for completing and distributing the form.  The original and third copy are sent to the DCSS.  Copies 1 and 2 are given to the parents.  A photocopy may be made for the case file.

 

 

CS 910 (1/97) C HOW A DECLARATION CAN HELP YOU AND YOUR NEW BABY

 

This is a one-page informational sheet for unmarried parents that provides a brief summary of the paternity declaration process.  Parents should be given this form along with the Declaration of Paternity.  This is a two-sided form with the English version on one side and Spanish on the other.

 

 

CS 915 (1/97) C RESCISSION FORM FOR THE DECLARATION OF PATERNITY

 

This is a one-page form that can be completed by either parent, notarized and filed with the State Office of Vital Records to rescind the voluntary declaration of paternity within 60 days from the date the declaration was signed.

 

 

PUB 244 (1/97) C ESTABLISHING PATERNITY FOR YOU AND YOUR CHILD

 

This is an eight-panel brochure that explains what paternity is and how a mother, father, and child will benefit from having paternity established.  The brochure can be used in conjunction with the Declaration of Paternity or may be used to provide general information about the program without the Declaration.

 

 

13.      FRC MEDICAL SUPPORT LIAISON

 

Each FRC office will designate an Eligibility Supervisor to serve as the Medical Support Referral contact person for their office.  DCSS will return incomplete or incorrect referrals received from district staff to the supervisor designated as the Medical Support Referral Liaison.

 

 

Any questions the workers have related to medical support should be discussed with their respective supervisor and not with DCSS staff, Revenue and Recovery, or Fiscal Services.

 


                         


APPENDIX A

GLOSSARY

 

The following are abbreviations, terms, and definitions that relate to the Child/Medical Support referral and enforcement program.

 

AF

Absent Father.

AM

Absent Mother.

AP

Absent Parent.

ARREARS

Refers to child or spousal support from a previous month/months which has not been paid.

ARTAS

Accounts Receivable Trust Fund: used by Revenue and Recovery.

ASSIGNMENT

Refers to:

                         1)      The client assigns his/her right to support to the County.

       2)      The AP's right to wages is assigned by the court to the County to satisfy a support obligation.

CSU

Child Support Unit:  refers to the Family Support Division's staff outstationed in the district offices.

CW

Complaining Witness:  refers to the person on whose behalf action for support enforcement is initiated.  The CW may be the mother, father, caretaker relative or County agency.

DA

Office of the District Attorney (see IV-D).

DEFENDANT

Refers to the person against whom a lawsuit is brought.

DISREGARD

Child support disregard refers to the amount up to $50 a client is eligible to out of monthly child support paid.

FSD

Family Support Division:  refers to the division of the District Attorney's Office responsible for child, medical and spousal support enforcement.

IS

Investigative Specialist:  refers to a staff position in FSD.  IS personnel provide technical support.  They may be outstationed at a district office or in the County Courthouse.  The primary function of the district IS is to interview custodial parents and evaluate individual cases.  The downtown IS performs other activities related to paternity establishment and support enforcement.

MEDICAL SUPPORT

Medical support is any liability or payment for the purpose of medical care available under a court or administrative order, including but not limited to health insurance, specific dollar amounts for medical purposes, and payments for medical care from any third party.

PATERNITY

Refers to a situation where male parentage is in question and must be established.

R & R

Revenue and Recovery:  The San Diego County Department responsible for the collection and processing of support monies.

SPOUSAL SUPPORT

Refers to month paid for the support of a former spouse (also referred to as alimony).

SUPPORT OBLIGATION

Refers to:

       1)      Monthly amounts accruing based on Medi-Cal paid or:

       2)      The amount of support ordered by a court.

TAX

Refers to the practice of deducting outstanding support obligations INTERCEPT                          from a state or federal tax refund.

TITLE IVD

Refers to the title of the Social Security Act that regulates the child support enforcement program.  In San Diego the District Attorney is the sole IVD agency.  (IVD refers to Medi-Cal.)

                         

                         


STATE OF CALIFORNIA, HEALTH AND WELFARE AGENCY                                                                                                                                                                CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

IMPORTANT NOTICE TO UNMARRIED PARENTS

 

If the parents of the child are not legally married, the father’s name will not be added to the birth certificate unless you: (1) sign a declaration of paternity in the hospital or (2) sign the form later or legally establish paternity through the courts and pay a fee to amend the birth certificate.

 

 

WHAT IS THE PURPOSE OF A DECLARATION OF PATERNITY?

 

A declaration of paternity form is used to legally establish the paternity (the father) of a child when the mother and father are not married to each other. It should be signed only by the biological parents of a child who were never married to each other. Signing this form is voluntary.

 

HOW WILL YOU AND YOUR CHILD BENEFIT IF YOU SIGN THIS FORM?

 

When both parents sign this form, it will:

 

·         Legally establish a parent-child relationship between the father and the child. Your child has the right to know his or her mother and father and to benefit from a relationship with both parents.

 

·         Allow the father’s name to be added to the birth certificate. Your child will benefit by having both of your names appear on his or her birth certificate. If the form is signed after the child’s birth certificate is prepared, there will be a fee to amend the birth certificate to add the father’s name.

 

·         Legally establish the man as the child’s father without going to court. This will give the father parental rights such as the right to seek child custody and visitation in a court action and to be consulted about the adoption of the child.

 

·         Make it easier for your child to learn the medical histories of both parents, to benefit from the father’s health care coverage, and to receive Social Security or Veterans’ dependent or survivor’s benefits, if eligible.

 

WHAT DOES IT MEAN IF YOU SIGN A DECLARATION OF PATERNITY?

 

·         A signed declaration of paternity that states that the man is the father will have the same effect as a court order establishing paternity for the child. If your child does not live with you and a court action is filed, you may be ordered by the court to pay child support. A court action must be filed to deal with the issues of custody, visitation or child support.

 

·         You have the right to a trial in court to decide the issue of paternity; to notice of any hearing on the issue of paternity; to have the opportunity to present your case to the court, including the right to present and cross examine witnesses; to have an attorney represent you; or to have an attorney appointed to represent you if you cannot afford one in an action filed by the District Attorney. By signing this declaration, you are, by your choice, giving up all of these rights.

 

·         If either of you later change your mind about signing the form, you must complete a form to rescind or cancel the declaration of paternity and file it with the State Office of Vital Records within sixty days from the date you sign this form. You can get a rescission form from your Family Support Division, or local office of vital statistics.

 

·         This form may be challenged in court only in the first two years after the child’s birth by using blood and genetic tests that prove the man is not the biological father. It also may be overturned if the father or mother is able to prove that he/she signed the form because of fraud, duress, or material mistake of fact.

 

·         If either or both of you are under the age of eighteen, a declaration of paternity will not establish paternity until sixty days after both of you are age eighteen or are emancipated. If you wish to legally establish paternity before both of you become adults, you should consult an attorney.

 

·         This is a legal document that will establish paternity sixty days from the date of signature. You do not have to complete or sign this form. If any part of this does not make sense to you, talk to your local Family Support Division or a lawyer before signing the form.

CS 909 (1/97) COVERSHEET


PATERNITY OPPORTUNITY PROGRAM

PATERNITY DECLARATION – INSTRUCTIONS FOR COMPLETION

(THIS FORM IS TO BE COMPLETED BY UNMARRIED PARENTS ONLY)

 

GENERAL

INFORMATION

The attached declaration form is to be used by unmarried parents to declare the father of the child. Paternity means legal fatherhood. Completing and signing this form is voluntary. THIS IS A LEGAL DOCUMENT. PLEASE CAREFULLY READ THE REVERSE SIDE OF THE FORM BEFORE YOU SIGN IT. There is important information about what it means to you and your child when you sign this form. In order for the Declaration of Paternity to be valid, both parents must complete and sign this form. The form must be signed in the presence of a witness from the hospital or agency accepting the form. If not signed at a hospital, prenatal clinic or public agency, you must sign the form in the presence of a notary public. If you are an unmarried father and you wish to have your name entered on the child’s birth certificate, you must sign this form. Otherwise, you must go to court to establish legal paternity and pay a fee to amend the child’s birth certificate to add your name. Please see the information for filing the form for more details.

 

PLEASE USE BLACK INK WHEN FILLING OUT THE ATTACHED FORM. PRINT ALL INFORMATION, EXCEPT FOR YOUR SIGNATURE. PLEASE PRESS FIRMLY AND PRINT CLEARLY WHEN FILLING OUT THE FORM.

 

SECTION A

This section is used to identify the mother, father, child and the birth place of the child. You do not have to write down your social security number. The number helps find parents so child support, and other benefits your child may need, may be collected. If you write down your social security number, it will be on any copies made of this form. All other lines in Section A must be completed.

 

SECTION B

In this section, both parents declare that they are the mother and father of the child named on this form. The signature and date signed must be completed by both parents for this form to be legal. PLEASE READ THE REVERSE SIDE OF THE FORM BEFORE YOU SIGN IT.

 

SECTION C

This section is to be completed by the person who is a witness to the parents’ signatures on the form. The witness must be an official representative of the hospital or agency accepting the form.

 

SECTION D

This section is to be completed ONLY when the form is witnessed by a notary public. If parents do not complete the form at a hospital, prenatal clinic or public agency, they can only sign it before a notary public. This section is to be completed and stamped by a notary public.

 

FILING THIS

FORM

When completed at a hospital, the hospital will send the original of this form to the local county registrar, along with the birth record. If your baby is not born in a hospital, this form must be submitted to your local registrar with the birth certificate in order to have the father’s name included on the birth record at the time you register the birth. In either case, the local registrar will file the form with the State Department of Health Services, Office of Vital Records, 304 S Street, Sacramento, CA 95814.

 

If you did not complete this form at the hospital (or when you registered your child’s birth), and you want to add the father’s name to the birth certificate, you must contact the State Department of Health Services, Office of Vital Records, 304 S Street, Sacramento, CA 95814. They will provide you with the additional forms you need to complete. You will be charged a fee to have your child’s birth certificate changed to include the father’s name.

 

If you did not complete this form at the hospital (or when you registered your child’s birth), and you do not want to update the birth certificate with the father’s name, you may still file this form with the State Department of Health Services, Office of Vital Records, 304 S Street, Sacramento, CA 95814.

 

Both parents will be given a copy of this form. This form is an important legal record. Parents should keep their copy in a safe place.

 

RESCINDING

THIS FORM

To rescind or cancel this form, either or both parents must complete and sign a Rescission Form for the Declaration of Paternity. This form must be filed with the State Office of Vital Records within sixty days of the date the paternity declaration was signed. To obtain a form to rescind or cancel this form, contact the Family Support Division of your local district attorney’s office or your local registrar of births and deaths.

 

CS 909 (1/97) COVERSHEET


STATE OF CALIFORNIA, HEALTH AND WELFARE AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

DECLARATION OF PATERNITY

                          DISTRIBUTION:         ORIGINAL – Vital Records

                                                              COPY 1 & 2 – Parents

                                                              COPY 3 – Family Support

SECTION A

Child

NAME OF CHILD – FIRST

 

MIDDLE

LAST

DATE OF BIRTH

 

SEX

FOR STATE USE ONLY

Place

of

Birth

HOSPITAL NAME

 

COUNTY

Father

NAME OF FATHER – FIRST

 

MIDDLE

LAST

SOCIAL SECURITY NO.

 

DATE OF BIRTH

PLACE OF BIRTH (STATE OR COUNTRY)

CURRENT ADDRESS (NUMBER, STREET, CITY, ZIP)

 

Mother

NAME OF MOTHER – FIRST

 

MIDDLE

LAST

SOCIAL SECURITY NO.

 

DATE OF BIRTH

PLACE OF BIRTH (STATE OR COUNTRY)

CURRENT ADDRESS (NUMBER, STREET, CITY, ZIP)

 

MAIDEN NAME

 

 

 

SECTION B – READ OTHER SIDE BEFORE SIGNING

I declare under the penalty of perjury under the laws of the State of California that I am the natural father of the child named on this declaration and that the information provided is true and correct. I have read and understand the rights and responsibilities described on the back of this form. I understand that by signing this form I am waiving those rights and consenting to the establishment of paternity. I am assuming all the rights and responsibilities of the natural father of this child. I wish to be named as the father on the child’s birth certificate.

I declare under the penalty of perjury under the State of California that I am the natural mother of the child named on this declaration and that the information provided is true and correct. I have read and understand the rights and responsibilities described on the back of this form. I certify that the man signing this form is the only possible father of this child. I know that by signing this form I am establishing the man named as father as the natural father of this child with all the rights and responsibilities of a natural father under the laws of California. I consent to the establishment of paternity by signing this form.

SIGNATURE OF FATHER

DATE SIGNED

SIGNATURE OF MOTHER

DATE SIGNED

SECTION C – TO BE COMPLETED BY WITNESS AT THE HOSPITAL, AGENCY OR CLINIC (PLEASE PRINT)

DECLARATION WITNESSED BY (SIGNATURE AND PRINTED NAME)

 

DATE

NAME OF AGENCY (HOSPITAL, CLINIC OR OTHER)

 

ADDRESS (ADDRESS, CITY AND ZIP CODE)

 

SECTION D – TO BE COMPLETED BY NOTARY PUBLIC IF NOT WITNESSED ABOVE

State of California

County of __________________________________________

On ___________________ before me, ____________________________________, personally

appeared______________________________________________________________________

______________________________________________________________________________

personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their signature(s) on the instrument the person(s), or the entity on behalf of which the person(s) acted, executed the instrument.

WITNESS by hand and official seal.

 

CS 909 (1/97)


WHAT IS THE PURPOSE OF A DECLARATION OF PATERNITY?

 

A declaration of paternity form is used to legally establish the paternity (the father) of a child when the mother and father are not married to each other. It should be signed only by the biological parents of a child who were never married to each other. Signing this form is voluntary.

 

HOW WILL YOU AND YOUR CHILD BENEFIT IF YOU SIGN THIS FORM?

 

This form when signed by both parents will:

 

·         Legally establish a parent-child relationship between the father and the child. Your child has the right to know his or her mother and father and to benefit from a relationship with both parents.

 

·         Allow the father’s name to be added to the birth certificate. Your child will benefit by having both of your names appear on his or her birth certificate. If the form is signed after the child’s birth certificate is prepared, there will be a fee to amend the birth certificate to add the father’s name.

 

·         Legally establish the man as the child’s father without going to court. This will give the father parental rights such as the right to seek child custody and visitation in a court action and to be consulted about the adoption of the child.

 

·         Make it easier for your child to learn the medical histories of both parents, to benefit from the father’s health care coverage, and to receive Social Security or Veterans’ dependent or survivor’s benefits, if eligible.

 

WHAT DOES IT MEAN IF YOU SIGN A DECLARATION OF PATERNITY?

 

·         A signed declaration of paternity that states that the man is the father will have the same effect as a court order establishing paternity for the child. If your child does not live with you and a court action is filed, you may be ordered by the court to pay child support. A court action must be filed to deal with the issues of custody, visitation or child support.

 

·         You have the right to a trial in court to decide the issue of paternity; to notice of any hearing on the issue of paternity; to have the opportunity to present your case to the court, including the right to present and cross examine witnesses; to have an attorney represent you; or to have an attorney appointed to represent you if you cannot afford one in an action filed by the District Attorney. By signing this declaration, you are, by your choice, giving up all of these rights.

 

·         If either of you later change your mind about signing the form, you must complete a form to rescind or cancel the declaration of paternity and file it with the State Office of Vital Records within sixty days from the date you sign this form. You can get a rescission form from your Family Support Division, or local office of vital statistics.

 

·         This form may be challenged in court only in the first two years after the child’s birth by using blood and genetic tests that prove the man is not the biological father. It also may be overturned if the father or mother is able to prove that he/she signed the form because of fraud, duress, or material mistake of fact.

 

·         If either or both of you are under the age of eighteen, a declaration of paternity will not establish paternity until sixty days after both of you are age eighteen or are emancipated. If you wish to legally establish paternity before both of you become adults, you should consult an attorney.

 

·         This is a legal document that will establish paternity sixty days from the date of signature. You do not have to complete or sign this form. If any part of this does not make sense to you, talk to your local Family Support Division or a lawyer before signing the form.


RESCISSION FORM FOR THE DECLARATION OF PATERNITY

 

PURPOSE: This form cancels the legal father and child relationship created by the Declaration of Paternity you have signed. It must be signed in front of a Notary Public and filed within 60 days of the date that the Declaration of Paternity was signed.

 

INSTRUCTIONS: Please read this entire form and carefully fill it out. Please use ink and print carefully. The form needs to be signed by only one parent to become official. You must send a letter to the other parent telling him or her that you are canceling the Declaration of Paternity form you both signed. A copy of the letter that you sent to inform the other parent must be filed with this form. Send this form, signed by you and a Notary Public, a copy of the letter and a check or money order for $19.00 made payable to the State Office of Vital Records at, 304 S Street, Sacramento, CA 95814. This fee is to change the original birth certificate.

 

STATEMENT OF PERSON FILING RESCISSION

 

                                  , state under oath:

                   (NAME OF PARENT SIGNING RESCISSION)

 

1.     I signed the Declaration of Paternity form for _________________________________ on ______________________

                                  (NAME OF CHILD)              (DATE SIGNED)

            at ________________________________________.

                                  (COUNTY/HOSPITAL SIGNED)

            My return address is ______________________________________________________________________.

 

2.     The child’s date of birth is ____________________________.

                                                    (MONTH/DAY/YEAR)

 

3.     The name of the other person who signed the Declaration is ______________________________________ and

                                          (NAME OF OTHER PARENT)

the address is _________________________________________________________________.

 

                                  (ADDRESS OF OTHER PARENT)

4.     My social security number is ______ - ______ - ___________. My date of birth is ___________________________.

                                  (OPTIONAL)                     (MONTH/DAY/YEAR)

 

5.     I want to cancel the legal father and child relationship created by the Declaration of Paternity. I understand that by signing this form I cancel the Declaration of Paternity, if it is filed with the State Office of Vital Records within 60 days of the date the Declaration of Paternity was signed.

           

_______________________________       ________________________________________________________

                                                    (YOUR SIGNATURE)          (YOUR ADDRESS)

This is a legal document. Please read and complete carefully. Do not sign this form if you do not understand what it means.

 


State of California

County of _______________________ On ______________ before me, __________________________________, personally appeared _________________________________ personally known to me (or proved on the basis of satisfactory evidence) to be the person(s) whose name(s) are subscribed to within instrument and acknowledged to me that he/she/they executed the same in his/her/their signature(s) on the instrument the person(s), or the entity on behalf of which the person(s) acted, executed the instrument.

 

 

 

 

WITNESS by hand and official seal.     Signature_______________________________________

 

For Office Use only:  Date filed with Office of Vital Records:_________________________________________.

 


CS 915 (1/97)

FORMULARIO PARA LA ANULACION DE LA DECLARACION DE PATERNIDAD

 

PROPOSITO: Este formulario cancela el parentesco legal que se creó entre el padre y el niño a través de la “Declaración de paternidad” que usted firmó. Este formulario se debe firmar en presencia de un notario público y se debe presentar antes de que pasen 60 días desde la fecha en que se firmó la “Declaración de paternidad”.

 

INSTRUCCIONES: Por favor, lea todo este formulario y llénelo con cuidado. Por favor, use tinta y escribe cuidadosamente con letra de imprenta. Sólo se necesita la firma de uno de los padres para que este formulario sea oficial. Usted tiene que mandarle al padre/madre una carta diciéndole que usted va a anular la “Declaración de paternidad” que ambos firmaron. Tiene que enviar junto con este formulario una copia de la carta que le mande al padre/madre. Envíe este formulario (firmado por usted y por un notario público), una copia de la carta, y un cheque o un giro (money order) por $19.00 a nombre de State Office of Vital Records a la siguiente dirección: 304 S Street, Sacramento, CA 95814. Esta cantidad es para cambiar el acta de nacimiento original.

 

DECLARACION DE LA PERSONA QUE PRESENTA LA ANULACION

 

Yo,                     , declaro bajo juramento que:

                     (NOMBRE DEL PADRE/MADRE QUE FIRMA LA ANULACION)

 

1.     Firmé el formulario de “Declaración de paternidad” en relación a ________________________________________

                                  (NOMBRE DEL NIÑO)                       

            el _____________________________ en __________________________________.

                                  (FECHA EN QUE LO FIRMO)            (CONDADO/HOSPITAL DONDE LO FIRMO)

            La dirección para enviarme correspondencia es_______________________________________________________.

 

2.     La fecha de nacimiento del niño es ____________________________.

                                                    (MES/DIA/AÑO)

 

3.     El nombre de la otra persona que firmó la declaración es _____________________________________________ y

                                          (NOMBRE DEL PADRE/MADRE)

su dirección es _________________________________________________________________.

                                  (DIRECCION DEL PADRE/MADRE)

 

4.     Mi número del seguro social es ______ - ______ - ___________. Mi fecha de nacimiento es ___________________.

                                  (OPCIONAL)                     (MES/DIA/AÑO)

 

5.     Deseo cancelar el parentesco legal que se creó entre el padre y el niño a través de la “Declaración de paternidad”. Yo comprendo que al firmar este formulario queda anulada la “Declaración de paternidad”, si es que lo envío a la Oficina Estatal del Registro Civil (State Office of Vital Records) antes de que pasen 60 días desde la fecha en que se firmó la “Declaración de paternidad”.

_______________________________       ________________________________________________________

                                                        (SU FIRMA)       (SU DIRECCION)

Este es un documento legal. Por favor léalo y complételo con cuidado. No firme este formulario si no comprende lo que significa.

 


ESTA SECCION LA TIENE QUE COMPLETAR UN NOTARIO PUBLICO

State of California

County of _______________________ On ______________ before me, __________________________________, personally appeared _________________________________ personally known to me (or proved on the basis of satisfactory evidence) to be the person(s) whose name(s) are subscribed to within instrument and acknowledged to me that he/she/they executed the same in his/her/their signature(s) on the instrument the person(s), or the entity on behalf of which the person(s) acted, executed the instrument.

 

WITNESS by hand and official seal.     Signature_______________________________________

Sólo para uso de la oficina:  Date filed with Office of Vital Records:______________________________________.

 


CS 915 (1/97) (SP)


Applicant/Custodial Parent Cooperates To Assign Their Rights To Medical Support

Applicant/Custodial Parent Cooperates To Establish Paternity

Applicant/Custodial Parent Cooperates In Providing Information About The Absent Parent

Good Cause Claimed

Good Cause Granted

Action Taken By The County Welfare Department

No

No

No

No

N/A

Deny Medi-Cal for custodial parent only and grant Medi-Cal for children if all other eligibility factors are met. Refer children for medical support enforcement.

Yes

No

No

No

N/A

Deny Medi-Cal for custodial parent only and grant Medi-Cal for children if all other eligibility factors are met. Refer children for medical support enforcement.

Yes

No

No

Yes

Yes

Grant Medi-Cal if all other eligibility factors are met while good cause is evaluated by CWD. When good cause is approved, continue Medi-Cal for custodial parent and children. Refer custodial parent to appropriate community, legal, medical and support services.

Yes

No

No

Yes

No

Grant Medi-Cal if all other eligibility factors are met while good cause is evaluated by CWD. When good cause is denied, refer case to the DA’s office to conduct a cooperation determination. When the cooperation determination is returned, the CWD will review and verify evidence that the applicant/ beneficiary refused to cooperate without good cause. Discontinue Medi-Cal for custodial parent and continue Medi-Cal for children. Refer children for medical support enforcement.

Yes

Yes

Yes

N/A

N/A

Grant Medi-Cal if all other eligibility factors are met. Refer children for medical support enforcement.