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Get CA DCSS 0569 2005

If there is a disagreement regarding the payment history the parties may be required to present proof of payments in the form of canceled checks receipts etc. Complete this Declaration neatly and correctly to make sure there is no mistake nor confusion as to the amounts of past due support owed if any. State of California - Health and Human Services Agency Department of Child Support Services INSTRUCTIONS FOR COMPLETING THE DECLARATION OF SUPPORT PAYMENT HISTORY You are asked to complete a month-by-month year-by-year breakdown of the amounts of support that were due ordered by the court and the amount of each payment that was made. In the Amount Paid column indicate a 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 amounts next to the month in which the payment was actually made and not the month or months which those payments were intended to cover. You may attach additional sheets as necessary. Be aware that this declaration is not confidential and may be given to the other parent in your case for review. These figures will help determine the amount of past due support owed if any. You must complete a separate page or pages 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. In the Amount Ordered column fill in the amount of support that became due each month since your court order began* If there has been a change in your court order make sure each month reflects the correct amount of support due. In the Amount Paid column indicate a 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 amounts next to the month in which the payment was actually made and not the month or months which those payments were intended to cover. You may attach additional sheets as necessary. Be aware that this declaration is not confidential and may be given to the other parent in your case for review. DCSS 0569 09/20/05 Person completing this form name I am the Custodial Party Noncustodial Parent Support Payment History For check one Unreimbursed medical expenses Child Family Medical Other specify YEAR AMOUNT ORDERED Spousal AMOUNT PAID January February March April May June July August September October November December I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I am aw are that this may be provided to the other parent for their verification and that either party may be required to provide documentation* Signature Date. These figures will help determine the amount of past due support owed if any. You must complete a separate page or pages 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. In the Amount Ordered column fill in the amount of support that became due each month since your court order began* If there has been a change in your court order make sure each month reflects the correct amount of support due. .

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  • spousal
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