Form DCSS0009 "Complaint Resolution Authorized Representative Form" - California

What Is Form DCSS0009?

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 July 1, 2003;
  • 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 DCSS0009 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 DCSS0009 "Complaint Resolution Authorized Representative Form" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
GRAY DAVIS, Governor
CALIFORNIA DEPARTMENT OF CHILD SUPPORT SERVICES
P.O. Box 419064, Rancho Cordova, CA 95741-9064
Reason for this Transmittal
October 15, 2003
[ ] State Law or Regulation Change
[ ] Federal Law or Regulation
Change
[ ] Court Order or Settlement
Change
[ ] Clarification requested by
CSS LETTER: 03-22
One or More Counties
[X] Initiated by DCSS
ALL IV-D DIRECTORS
ALL COUNTY ADMINISTRATIVE OFFICERS
ALL BOARDS OF SUPERVISORS
SUBJECT:
COMPLAINANT’S AUTHORIZED REPRESENTATIVE DURING
COMPLAINT RESOLUTION
REFERENCE: CALIFORNIA CODE OF REGULATIONS, TITLE 22, DIVISION 13,
CHAPTER 1, SUBCHAPTER 1, ARTIC LE 5, SECTION 111440 AND
CHAPTER 10.
This letter implements State policy regarding a child support complainant’s right to appoint
an authorized representative during all aspects of the complaint resolution process by
signing and dating a written statement to that effect. The complainant may use the
enclosed “Complaint Resolution Authorized Representative Form,” DCSS 0009 dated
(07/03) to designate an authorized representative. Amendments to the California Code of
Regulations regarding this policy will be submitted to the Office of Administrative Law in
the near future.
The complainant’s authorization may be limited in scope or duration by the complainant,
and may be revoked by the complainant at any time. Whenever the complainant is
represented by an authorized representative, the local child support agency shall provide
the authorized representative with copies of all notices and decisions concerning complaint
resolution that are provided to the complainant.
The authorized representative shall have the same right as the complainant to review the
complainant’s case record pursuant to Chapter 1, Program Administration, Article 5,
Records Management. All rights and responsibilities specified in Chapter 10, Article 2,
shall apply to a duly authorized representative, unless the authorization is limited by the
complainant.
DCSS-PR-2003-POL-0008
D
Y
P
T
H
C
S
E
O
OUR
ART
O
ELP
ALIFORNIA
AVE
NERGY
For energy saving tips, visit the DCSS website at
www.childsup.cahwnet.gov
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
GRAY DAVIS, Governor
CALIFORNIA DEPARTMENT OF CHILD SUPPORT SERVICES
P.O. Box 419064, Rancho Cordova, CA 95741-9064
Reason for this Transmittal
October 15, 2003
[ ] State Law or Regulation Change
[ ] Federal Law or Regulation
Change
[ ] Court Order or Settlement
Change
[ ] Clarification requested by
CSS LETTER: 03-22
One or More Counties
[X] Initiated by DCSS
ALL IV-D DIRECTORS
ALL COUNTY ADMINISTRATIVE OFFICERS
ALL BOARDS OF SUPERVISORS
SUBJECT:
COMPLAINANT’S AUTHORIZED REPRESENTATIVE DURING
COMPLAINT RESOLUTION
REFERENCE: CALIFORNIA CODE OF REGULATIONS, TITLE 22, DIVISION 13,
CHAPTER 1, SUBCHAPTER 1, ARTIC LE 5, SECTION 111440 AND
CHAPTER 10.
This letter implements State policy regarding a child support complainant’s right to appoint
an authorized representative during all aspects of the complaint resolution process by
signing and dating a written statement to that effect. The complainant may use the
enclosed “Complaint Resolution Authorized Representative Form,” DCSS 0009 dated
(07/03) to designate an authorized representative. Amendments to the California Code of
Regulations regarding this policy will be submitted to the Office of Administrative Law in
the near future.
The complainant’s authorization may be limited in scope or duration by the complainant,
and may be revoked by the complainant at any time. Whenever the complainant is
represented by an authorized representative, the local child support agency shall provide
the authorized representative with copies of all notices and decisions concerning complaint
resolution that are provided to the complainant.
The authorized representative shall have the same right as the complainant to review the
complainant’s case record pursuant to Chapter 1, Program Administration, Article 5,
Records Management. All rights and responsibilities specified in Chapter 10, Article 2,
shall apply to a duly authorized representative, unless the authorization is limited by the
complainant.
DCSS-PR-2003-POL-0008
D
Y
P
T
H
C
S
E
O
OUR
ART
O
ELP
ALIFORNIA
AVE
NERGY
For energy saving tips, visit the DCSS website at
www.childsup.cahwnet.gov
CSS Letter: 03-22
October 15, 2003
Page 2
If you have any questions or concerns regarding this policy, please contact the Policy
Branch at Policy.Branch@dcss.ca.gov.
Sincerely,
DONNA S. HERSHKOWITZ
Deputy Director
Child Support Services Division
DCSS-PR-2003-POL-0008
STATE OF CALIFORNIA - HEALTH AND HUM AN SERVICES AGENCY
DEPARTMENT OF CHILD SUPPORT SERVICES
COMPLAINT RESOLUTION AUTHORIZED REPRESENTATIVE FORM
DCSS 0009 (07/03)
I hereby appoint the person named below to serve as my authorized representative for the
purpose of conducting business on my behalf during the Complaint Resolution process. I give
my permission for this person to discuss any facts related to my complaint and to receive
copies of documents related to my complaint, except as noted below.
COMPLAINANT' S NAME (PLEASE PRINT)
TELEPHONE NUMBER
(
)
DATE
COMPLAINANT' S SIGNATURE
ADDRESS
CITY
STATE
ZIP CODE
COUNTY OF COMPLAINT
COUNTY' S CHILD SUPPORT CASE NUMBER
THIS AUTHORIZATION EXPIRES ON:
(MONTH / DAY/ YEAR)
(THIS DATE IS OPTIONAL)
THIS AUTHORIZATION IS LIMITED BY THE FOLLOWING CONDITIONS (IF APPLICABLE):
AUTHORIZED REPRESENTATIVE INFORMATION
NAME OF AUTHORIZED REPRESENTATIVE (PLEASE PRINT)
TELEPHONE NUMBER
(
)
AUTHORIZED REPRESENTATIVE'S SIGNATURE
DATE
ADDRESS
E-MAIL ADDRESS
CITY
STATE
ZIP CODE
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