Form DCSS0678 "Certification of Annual Service Fee Exemption" - California

What Is Form DCSS0678?

This is a legal form that was released by the California Department of Child Support 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 23, 2011;
  • The latest edition provided by the California Department of Child Support 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 DCSS0678 by clicking the link below or browse more documents and templates provided by the California Department of Child Support Services.

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Download Form DCSS0678 "Certification of Annual Service Fee Exemption" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF CHILD SUPPORT SERVICES
CERTIFICATION OF ANNUAL SERVICE FEE EXEMPTION
DCSS 0678 (08/23/11)
The Federal Deficit Reduction Act of 2005 (Public Law 109-171) requires that all state child support agencies
impose an Annual Service Fee for cases that meet the following criteria: (1) The Department of Child Support
Services is providing services to the custodial party on the case. (2) The custodial party on the case has
never received public assistance under Title IV-A of the Social Security Act. (3) $500 or more has been
disbursed to the family on each case for the prior Federal Fiscal Year (October 1- September 30). You may
be exempt from being charged the Annual Service Fee if you meet one of the qualifying conditions in either
Section II or III.
Section I: Personal Information
Last Name
First Name
Middle Name
City
State
Return Mailing Address (number and street)
Zip Code
Participant Number
Phone Number (include area code)
Affected Case Number(s)
Section II: Permanent Exemption
Country
I am a Foreign Obligee with a primary address in either the United
States or a U.S. Territory.
I receive(d) public assistance under one of the following programs:
State
Date Aid Began
Date Aid Ended
Aid to Families with Dependent Children
(Cash AFDC)
State
Date Aid Began
Date Aid Ended
Temporary Assistance for Needy Families
(Cash TANF)
State
Date Aid Began
Date Aid Ended
Tribal TANF Program
Section III: One-Time Exemption
State
Date Paid
I already paid the Annual Service Fee in
another state.
I did not receive the full $500 in support payments
between October 1 and September 30.
Please Return the Completed Form to the Address Below:
California Department of Child Support Services
Office of Payment Management & Intergovernmental Services
PO Box 419064, MS-161
Rancho Cordova, CA 95741-9064
I certify under penalty of perjury that the above is true and correct.
Signature
Date
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF CHILD SUPPORT SERVICES
CERTIFICATION OF ANNUAL SERVICE FEE EXEMPTION
DCSS 0678 (08/23/11)
The Federal Deficit Reduction Act of 2005 (Public Law 109-171) requires that all state child support agencies
impose an Annual Service Fee for cases that meet the following criteria: (1) The Department of Child Support
Services is providing services to the custodial party on the case. (2) The custodial party on the case has
never received public assistance under Title IV-A of the Social Security Act. (3) $500 or more has been
disbursed to the family on each case for the prior Federal Fiscal Year (October 1- September 30). You may
be exempt from being charged the Annual Service Fee if you meet one of the qualifying conditions in either
Section II or III.
Section I: Personal Information
Last Name
First Name
Middle Name
City
State
Return Mailing Address (number and street)
Zip Code
Participant Number
Phone Number (include area code)
Affected Case Number(s)
Section II: Permanent Exemption
Country
I am a Foreign Obligee with a primary address in either the United
States or a U.S. Territory.
I receive(d) public assistance under one of the following programs:
State
Date Aid Began
Date Aid Ended
Aid to Families with Dependent Children
(Cash AFDC)
State
Date Aid Began
Date Aid Ended
Temporary Assistance for Needy Families
(Cash TANF)
State
Date Aid Began
Date Aid Ended
Tribal TANF Program
Section III: One-Time Exemption
State
Date Paid
I already paid the Annual Service Fee in
another state.
I did not receive the full $500 in support payments
between October 1 and September 30.
Please Return the Completed Form to the Address Below:
California Department of Child Support Services
Office of Payment Management & Intergovernmental Services
PO Box 419064, MS-161
Rancho Cordova, CA 95741-9064
I certify under penalty of perjury that the above is true and correct.
Signature
Date