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State of California Health and Human Services AgencyDepartment of Developmental Services DS 1235A (Rev. 12/2018)FAMILY FINANCIAL STATEMENT STAFF USE ONLY CHECK ASSESSMENT TYPE InitialARedeterminationChange.

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How to fill out the CA DS 1235A online

The CA DS 1235A form is an essential document for families seeking financial assistance for a child with developmental disabilities. This guide provides clear, step-by-step instructions for filling out the form online, ensuring users can complete it accurately and efficiently.

Follow the steps to complete the form with ease.

  1. Click ‘Get Form’ button to access the CA DS 1235A form electronically.
  2. Begin by filling in the child's information in section A, which includes the child’s first name, middle name, last name, date of placement, suffix, account number or Unique Client Identifier (UCI), date of birth, Social Security number, regional center name, care facility name, care facility phone number, and care facility address.
  3. Next, provide the family size in section B by listing first names, last names, ages, and relationships to the child for each person living in the household, ensuring all relevant data is captured. If there are more dependents, attach additional sheets as necessary.
  4. In section C, share your personal details as the parent completing the form, including your first name, middle name, last name, suffix, date of birth, home address, relationship to the child, contact numbers, email address, Social Security number, and employment status.
  5. If applicable, fill out the information pertaining to your spouse living in the home in section D, repeating similar fields as in section C, including employment details.
  6. For section E, report all sources of income for you and your spouse. Indicate the gross amounts for each income source and ensure proof of income is provided.
  7. In section F, if applicable, outline any deductions, specifying the monthly amounts paid for alimony or child support paid to the child's parent or the regional center, accompanied by necessary proof.
  8. Finally, complete the signature section by signing and dating the form, along with your spouse's signature if applicable, confirming the accuracy of the information provided.
  9. After thoroughly reviewing all entries for accuracy, you can save your changes, download the form, print it, or share it as needed.

Start completing the CA DS 1235A online today to ensure you have the support needed for your child's development.

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