Form CW2.1 "Notice and Agreement for Child, Spousal and Medical Support" - California

What Is Form CW2.1?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2004;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CW2.1 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form CW2.1 "Notice and Agreement for Child, Spousal and Medical Support" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Complete one form for each noncustodial
NOTICE AND AGREEMENT FOR
parent or alleged father.
CHILD, SPOUSAL AND MEDICAL SUPPORT
Assignment and Cooperation Rules
Benefits of Cooperation
You must assign (give to) the county any rights you may have
Your cooperation can help you and your child(ren). Finding
for:
the noncustodial parent and establishing paternity may give
Any child or spousal support payments you get while
you and your child(ren) rights to future social security, veter-
receiving cash aid.
ans, or other benefits. The LCSA will continue enforcement
Medical support you get while getting Medi-Cal.
after you go off cash aid or Medi-Cal unless you make a
request in writing to the LCSA to stop.
The receipt of a cash aid payment and/or Medi-Cal Benefits
Identification Card (BIC) will assign the past and present
Good Cause for Not Cooperating
support rights of all persons for whom you are requesting
cash aid and/or medical assistance. You will be sent facts on
Good cause is the right to refuse to cooperate because it
the amount of support the county gets from the noncustodial
is not in the best interests of you or your child(ren).
parent(s).
You have the right to claim good cause for not
Cooperation
cooperating if you have an acceptable reason for refusing
You must cooperate with the county and the Local Child
to cooperate with the county and the LCSA.
Support Agency (LCSA) to:
Identify and locate any noncustodial parent/alleged father
The back of this form gives you facts about good cause.
in your case;
If you want more facts about good cause and/or refusal to
Tell the county or LCSA any time you get facts about the
cooperate, ask your worker to explain them to you.
noncustodial parent/alleged father, such as place of
residence or work location;
Penalty for Refusal to Cooperate
Agree to cooperate in the support enforcement process or
to claim good cause for refusing to cooperate by
If you do not have good cause, there are penalties if you
completing this Notice and Agreement;
refuse to assign support rights, refuse or fail to give the county
Complete the Child Support Questionnaire (CW 2.1Q) for
any support given to you by the noncustodial parent(s), or
each noncustodial parent or alleged father;
refuse to cooperate with the LCSA, including in determining
Establish paternity and get child and/or spousal support;
Submit to genetic testing if paternity is in question;
paternity.
Obtain any other payments or property due any member
of your assistance unit;
For cash aid applicants/recipients:
Obtain medical support money from any noncustodial
_
If you refuse to assign support rights or refuse/fail to
parent and, if you get cash aid, obtain child support
money;
give the county any support given to you, you will not
Tell the county about medical coverage or money for
be eligible for cash aid or Medi-Cal. Your child(ren)
medical services paid by the noncustodial parent and
may still be eligible for aid/benefits and your case will
complete the Health Insurance Questionnaire form
be referred to the LCSA.
(DHS 6155);
_
Give the LCSA any medical support money from any
If you refuse or fail to cooperate in the paternity or
noncustodial parent, and any child/spousal support
support enforcement process, your family’s grant will
money you get;
be lowered by 25 percent until you cooperate and you
Appear at the county or LCSA office to sign papers or
may not get Medi-Cal. This penalty ends effective
give required facts;
Appear at hearings or in court when necessary;
the first day of the month in which you do cooperate.
Fill out and sign an Attestation Statement, if asked by the
LCSA. On this form you declare under penalty of
For applicants/beneficiaries of Medi-Cal Only:
You
perjury that you have given all the facts you know about
will not be eligible for Medi-Cal benefits, but your
the noncustodial parent/alleged father. If you sign the
child(ren) may still be eligible.
form and you do not report all the facts or give wrong
facts, you can be fined or sent to jail/prison.
NAME OF NONCUSTODIAL PARENT/ALLEGED FATHER
Certification and Agreement:
I understand my rights and responsibilities as written on this notice.
I understand the rules for assigning support rights to the county.
I also understand my right to claim good cause.
I refuse to assign child/spousal support rights
(cash aid).
I agree to cooperate with the county and the LCSA as listed above.
I refuse to assign medical support rights (cash
I claim good cause and refuse to cooperate at this time.
aid and Medi-Cal).
Signature of Parent or Caretaker Relative,
Date
Case Name
Case Number
or Medi-Cal Applicant/Beneficiary
I certify that I have notified the applicant, cash aid recipient, or Medi-Cal beneficiary of his/her rights and responsibilities by
means of this notice and orally as needed.
County Worker’s Signature
Worker’s Number
Date
CW 2.1 NOTICE AND AGREEMENT (8/04) REQUIRED FORM - SUBSTITUTE PERMITTED
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Complete one form for each noncustodial
NOTICE AND AGREEMENT FOR
parent or alleged father.
CHILD, SPOUSAL AND MEDICAL SUPPORT
Assignment and Cooperation Rules
Benefits of Cooperation
You must assign (give to) the county any rights you may have
Your cooperation can help you and your child(ren). Finding
for:
the noncustodial parent and establishing paternity may give
Any child or spousal support payments you get while
you and your child(ren) rights to future social security, veter-
receiving cash aid.
ans, or other benefits. The LCSA will continue enforcement
Medical support you get while getting Medi-Cal.
after you go off cash aid or Medi-Cal unless you make a
request in writing to the LCSA to stop.
The receipt of a cash aid payment and/or Medi-Cal Benefits
Identification Card (BIC) will assign the past and present
Good Cause for Not Cooperating
support rights of all persons for whom you are requesting
cash aid and/or medical assistance. You will be sent facts on
Good cause is the right to refuse to cooperate because it
the amount of support the county gets from the noncustodial
is not in the best interests of you or your child(ren).
parent(s).
You have the right to claim good cause for not
Cooperation
cooperating if you have an acceptable reason for refusing
You must cooperate with the county and the Local Child
to cooperate with the county and the LCSA.
Support Agency (LCSA) to:
Identify and locate any noncustodial parent/alleged father
The back of this form gives you facts about good cause.
in your case;
If you want more facts about good cause and/or refusal to
Tell the county or LCSA any time you get facts about the
cooperate, ask your worker to explain them to you.
noncustodial parent/alleged father, such as place of
residence or work location;
Penalty for Refusal to Cooperate
Agree to cooperate in the support enforcement process or
to claim good cause for refusing to cooperate by
If you do not have good cause, there are penalties if you
completing this Notice and Agreement;
refuse to assign support rights, refuse or fail to give the county
Complete the Child Support Questionnaire (CW 2.1Q) for
any support given to you by the noncustodial parent(s), or
each noncustodial parent or alleged father;
refuse to cooperate with the LCSA, including in determining
Establish paternity and get child and/or spousal support;
Submit to genetic testing if paternity is in question;
paternity.
Obtain any other payments or property due any member
of your assistance unit;
For cash aid applicants/recipients:
Obtain medical support money from any noncustodial
_
If you refuse to assign support rights or refuse/fail to
parent and, if you get cash aid, obtain child support
money;
give the county any support given to you, you will not
Tell the county about medical coverage or money for
be eligible for cash aid or Medi-Cal. Your child(ren)
medical services paid by the noncustodial parent and
may still be eligible for aid/benefits and your case will
complete the Health Insurance Questionnaire form
be referred to the LCSA.
(DHS 6155);
_
Give the LCSA any medical support money from any
If you refuse or fail to cooperate in the paternity or
noncustodial parent, and any child/spousal support
support enforcement process, your family’s grant will
money you get;
be lowered by 25 percent until you cooperate and you
Appear at the county or LCSA office to sign papers or
may not get Medi-Cal. This penalty ends effective
give required facts;
Appear at hearings or in court when necessary;
the first day of the month in which you do cooperate.
Fill out and sign an Attestation Statement, if asked by the
LCSA. On this form you declare under penalty of
For applicants/beneficiaries of Medi-Cal Only:
You
perjury that you have given all the facts you know about
will not be eligible for Medi-Cal benefits, but your
the noncustodial parent/alleged father. If you sign the
child(ren) may still be eligible.
form and you do not report all the facts or give wrong
facts, you can be fined or sent to jail/prison.
NAME OF NONCUSTODIAL PARENT/ALLEGED FATHER
Certification and Agreement:
I understand my rights and responsibilities as written on this notice.
I understand the rules for assigning support rights to the county.
I also understand my right to claim good cause.
I refuse to assign child/spousal support rights
(cash aid).
I agree to cooperate with the county and the LCSA as listed above.
I refuse to assign medical support rights (cash
I claim good cause and refuse to cooperate at this time.
aid and Medi-Cal).
Signature of Parent or Caretaker Relative,
Date
Case Name
Case Number
or Medi-Cal Applicant/Beneficiary
I certify that I have notified the applicant, cash aid recipient, or Medi-Cal beneficiary of his/her rights and responsibilities by
means of this notice and orally as needed.
County Worker’s Signature
Worker’s Number
Date
CW 2.1 NOTICE AND AGREEMENT (8/04) REQUIRED FORM - SUBSTITUTE PERMITTED
YOUR RIGHT TO CLAIM GOOD CAUSE
What Is Acceptable Evidence to Claim Good Cause for
Not Cooperating?
Reasons for Claiming Good Cause:
Birth certificates, medical/mental health, rape crisis,
domestic violence program, or police/sheriff records that
Cooperation would increase the risk of physical, sexual,
or emotional harm to the child(ren).
show that the child(ren) was conceived due to incest or
rape.
Cooperation would increase the risk of domestic abuse
Records that show you have asked for help with abuse
for the parent or caretaker relative.
toward you and/or the child(ren); or records that show
evidence of abuse. These records can be from
The child(ren) was conceived due to incest or rape.
police/sheriff, governmental agency, or court records;
facts from a domestic violence program or a professional
Court proceedings are going on for the adoption of the
child(ren).
from whom you have asked for help in dealing with
abuse; physical evidence of abuse, or any other
You are working with an adoption agency to help you
evidence that supports an exemption from the
cooperation rules.
decide whether to keep or place the child(ren) for
adoption.
Court documents or other records that show that a legal
You are cooperating in good faith but are not able to
adoption is pending in court.
identify or help locate the noncustodial parent.
A written statement from an adoption agency confirming
that you are being helped to decide whether to keep or
You have other credible reasons why cooperation would
not be in the best interest of the child(ren).
place your child(ren) up for adoption.
How to Claim Good Cause:
Credible sworn statements under penalty of perjury about
the history of abuse or the increased risk of abuse, from
If you want to claim good cause, you must tell your
either you or other people who know about the reasons
for your good cause claim for not cooperating.
worker. You can do this whenever you believe you have
good cause not to cooperate.
The Role of the Local Child Support Agency (LCSA):
You must also complete and sign the Good Cause Claim
If you request a hearing on the issue of good cause, the
form which your worker will give you.
LCSA may take part in that hearing.
If you claim good cause, you must:
The LCSA may try to establish paternity or collect child
_
Give the county proof that you have good cause for
support if:
refusing to cooperate.
_
Establishing paternity or collecting child support will
_
not increase risk of harm to you or the child(ren).
Give the proof to the county within 20 days of
claiming good cause. The county will give you more
_
You do not have good cause for refusing to
time if it determines that you need more than
20 days to get your proof.
cooperate.
If you are claiming good cause and it is not possible for
After the county tells the LCSA that an applicant/recipient
has claimed to be exempt from the cooperation rules, the
you to get proof, tell the worker.
LCSA will not pursue child support enforcement
The Role of the County:
activities unless the applicant/recipient asks for these
actions to begin or to begin again.
The county reviews your Good Cause Claim and the
proof you provide and decides whether you have
good cause.
The county investigates your facts.
The county will tell you when you need to provide:
_
more proof to support your good cause claim, and/or
_
additional facts so that it will not be necessary to
contact the noncustodial parent or alleged father.
CW 2.1 NOTICE AND AGREEMENT (8/04) REQUIRED FORM - SUBSTITUTE PERMITTED
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