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ALAMEDA COUNTY DEPARTMENT OF CHILD SUPPORT SERVICES 5669 GIBRALTAR DR PLEASANTON CA 94588-8547

Custodial Party: MAIKO ROSS


MAIKO ROSS 24100 AMADOR ST HAYWARD CA 94544-1273

CP Participant Number: 0010000176394 Collection Month: 7/2013 Date of Notice: 07/31/2013

Dear MAIKO ROSS:

This is your monthly statement of child support collections and distributions.


1. TOTAL COLLECTIONS: $282.00

2. TOTAL DISTRIBUTIONS: $235.29

Received CalWORKs:
Current support paid to you: Disregard paid to you: Current support applied to repay CalWORKs: Past due support paid to you: Past due support applied to repay CalWORKs: Excess support paid to you: Other:

Yes
$235.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

X No

The dollar amounts for "Total Collections" and "Total Distributions" provided above may not be the same because collections may be received in one month and distributed to you in another month. If you were a CalWORKs recipient during the month of this statement and did not receive a disregard payment it is for one of the following reasons: There is no current support order for which a collection has been received. According to federal law, some collections received can only be applied to repay CalWORKs previously paid to you. If this type of collection was received the collection date will appear here:
If you have any questions, please visit CustomerConnect at https://www.childsup-connect.ca.gov or call (866) 901-3212 for assistance. Persons with hearing or speech impairments, please call the TTY number (866) 399-4096.
MONTHLY STATEMENT OF COLLECTIONS AND DISTRIBUTION DCSS 0281 (01/19/12) STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES Page 1

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DS2256065588

3. COLLECTIONS BY CASE NUMBER: Date Received 06/27/2013 07/11/2013 07/25/2013 Case Number
0010532105-01 0010532105-01 0010532105-01

Amount Received
$46.71 $68.48 $62.28

Date Case Number Amount Received Received 07/05/2013 0010532105-01 $64.21 07/18/2013 0010532105-01 $40.32

4. DISTRIBUTIONS BY CASE NUMBER: Case Number


0010532105-01

NOTE: Includes payments that were either paid to you or applied to repay CalWORKs. "Disregard" and "Excess" payments are shown as paid to you. Distributions identified as "Other" are not shown.

Current Support Paid to You $235.29

Past Due Support Paid to You $0.00

Support Applied to Repay CalWORKs $0.00

MONTHLY STATEMENT OF COLLECTIONS AND DISTRIBUTION DCSS 0281 (01/19/12)

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF CHILD SUPPORT SERVICES Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF CHILD SUPPORT SERVICES

NOTICE REGARDING MONTHLY STATEMENT OF COLLECTIONS AND DISTRIBUTION


DCSS 0279 (05/14/12)

THIS NOTICE HAS IMPORTANT INFORMATION THAT WILL HELP YOU UNDERSTAND YOUR MONTHLY CHILD SUPPORT STATEMENT - PLEASE READ IT CAREFULLY
The Monthly Statement of Collections and Distribution (DCSS 0281) informs you of collections received and distributed during the month identified on the statement. If you believe any information on your statement is incorrect, you should contact your local child support agency at (866) 901-3212. For information about the complaint resolution process, please see the enclosed form Complaint Resolution-State Hearing Information (DCSS 0642). NOTE: You will only receive a statement if collections were received for, or distributed to, your case(s) within the month.

The amounts reported in Section 1 (TOTAL COLLECTIONS) and Section 2 (TOTAL DISTRIBUTIONS) may not be the same because collections may be received in one month and distributed to your case or paid to you in another month. In addition, a change in your circumstances (i.e. retroactive changes to court ordered support, receiving California Work Opportunity and Responsibility to Kids (CalWORKs), etc.) that occurs after the date in which information for your statement was collected may not be reflected on your statement. 1. TOTAL COLLECTIONS: The total amount of collections applied to the case(s) for the month. This amount may include adjustments, such as collections that were applied, reversed, and then reapplied. 2. TOTAL DISTRIBUTIONS: The total amount of collections distributed to your case(s), including adjustments, as follows: Received CalWORKs: Indicates whether or not you received CalWORKs during the month. Current support paid to you: The total amount collected for your case(s) paid to you as current support during the month.

Disregard paid to you: The amount of the collection paid to you as a disregard payment if you received CalWORKs during the month. If you received CalWORKs, you are entitled to receive up to the first $50 collected for current support. This $50 limit applies even if current support is received from more than one parent or for more than one child. This collection amount is called a disregard because it is not counted against your eligibility for public assistance. The disregard payment is sent to you within two business days from the date the current support payment was collected. If a collection date does not appear at the end of the second bullet under Section 2, this does not apply to you. If a collection date does appear, it means that a collection(s) was received, that, according to federal law, can only be applied to repay CalWORKs previously paid to you. Current support applied to repay CalWORKs: The total amount collected for your case(s) from current support that was applied to repay CalWORKs. Past due support paid to you: The total amount collected for your case(s) paid to you for past due support. Past due support applied to repay CalWORKs: The total amount collected for your case(s) from past due support that was applied to repay CalWORKs.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF CHILD SUPPORT SERVICES

NOTICE REGARDING MONTHLY STATEMENT OF COLLECTIONS AND DISTRIBUTION


DCSS 0279 (05/14/12)

Excess support paid to you: The total amount paid to you after all CalWORKs has been repaid. Excess support can come from either current support or past due support. The total amount of CalWORKs that may be recovered is limited to the total amount of assistance that has been paid to you. The amount to be repaid may be recovered from support collections assigned as a condition of receiving CalWORKs. Other: This amount may include an adjustment or fees as follows: Adjustment An adjustment is made to correct an error so that a collection(s) can be applied or reapplied correctly. The adjusted amount is included in the total dollar amount reported in Section 1 (TOTAL COLLECTIONS) and Section 2 (TOTAL DISTRIBUTIONS), and is specifically reported in "Other". Each adjustment is reported in detail (date, case number and amount received) in Section 3 (COLLECTIONS BY CASE NUMBER). Note that a collection that has been reversed will appear as a collection received. The dollar amount(s) reported in Section 4 (DISTRIBUTIONS BY CASE NUMBER) is the resulting distribution(s) after an adjustment(s) has been made. Fee An annual $25 application fee is charged to families that have never received Temporary Assistance for Needy Families (TANF) if at least $500 is collected annually on their behalf. The fee is assessed annually in October for cases meeting this criteria. Once the fee is assessed it will be collected from the custodial party's next support payment(s) until the $25 is paid in full. NOTE: Information obtained from the Customer Connect phone number or website may not be the same as your statement due to adjustments made to your case(s).

3. COLLECTIONS BY CASE NUMBER: Detailed information about the collection(s) for your case(s), including adjustments, during the month as follows: Date Received: The date the collection was received. Case Number: The case number for which the collection was applied. Amount Received: The dollar amount of the collection received. NOTE: Collection adjustments will be stated with the same date received as the original collection. 4. DISTRIBUTIONS BY CASE NUMBER: Detailed information about the distribution(s) to your case(s) during the month, whether paid to you or applied to repay CalWORKs, as follows: Case Number: The case number for which the payments received were applied. Current Support Paid to You: Includes "Disregard" and/or "Excess" payments if stated in Section 2. Past Due Support Paid to You: Includes "Excess" payments if stated in Section 2. Support Applied to Repay CalWORKs: The total amount of support that was applied to repay CalWORKs. NOTE: "Other" distributions will not be stated in this section.
If you have new information about the other parent's income, employment, assets, or change of address for you or the other parent, please contact your local child support agency at (866) 901-3212.

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COMPLAINT RESOLUTION - STATE HEARING INFORMATION


RIGHT TO COMPLAINT RESOLUTION: If you have a complaint against a local child support agency for any action or inaction regarding your child support case, you have the right to request complaint resolution from the local child support agency. You can make a complaint in writing by completing the Request for Complaint Resolution form, or you can call the local child support agency. IMPORTANT: Your request for complaint resolution must be made within 90 days from the date you knew, or should have known, about the subject of your complaint. The local child support agency has 30 days from the date it receives your complaint to give you a written resolution of your complaint, unless the local child support agency needs more information or time to resolve your complaint. The local child support agency will contact you if it needs more information or time to resolve your complaint. RIGHT TO A STATE HEARING: If the local child support agency does not respond to you within 30 days from receiving your complaint, you have the right to request a State Hearing before an Administrative Law Judge. IMPORTANT: Your request for a State Hearing must be made within 90 days after you complained to the local child support agency. If the local child support agency does respond to you within 30 days of making your complaint, and you are not satisfied with the local child support agency's complaint resolution or response, you have the right to request a State Hearing before an Administrative Law Judge. IMPORTANT: Your request for State Hearing must be made within 90 days after you received the local child support agency's written response to your complaint. You can request a State Hearing in writing by sending a Request for State Hearing form to the State Hearing Office, or you can call the State Hearing Office toll free at 1-866-289-4714. The State Hearing Office will let you know the date, time, and place of your State Hearing. The State Hearing Office will provide an interpreter or disability accommodation for you at the hearing if you need one. IMPORTANT: Not all complaints can be heard at a State Hearing. State Hearings will only be granted for the following issues: An application for child support has been denied or has not been acted upon within the required time frame. The child support services case has been acted upon in violation of federal or state law or regulation, or California Department of Child Support Services policy letter, or has not been acted on within the required timeframe, including services for the establishment, modification, and enforcement of child support orders and child support accountings. Child support collections have not been distributed, or have been distributed or disbursed incorrectly, or the amount of child support arrears, as calculated by the local child support agency is inaccurate. The local child support agency's decision to close a child support case. IMPORTANT: The following issues cannot be heard at a State Hearing: Child support issues that must be addressed by motion, order to show cause, or appeal in a court. A review of any court order for child support or child support arrears. A court order or equivalent determination of paternity. A court order for spousal support. Child custody determinations. Child visitation determinations. Complaints of alleged discourteous treatment by a local child support agency employee, unless such conduct resulted in a hearable action or inaction. OMBUDSPERSON SERVICES: Every local child support agency has an Ombudsperson available to help you through the complaint resolution and/or State Hearing process. The Ombudsperson can help you obtain information regarding your complaint to help you prepare for your State Hearing. IMPORTANT: The Ombudsperson cannot represent you at the State Hearing or give you legal advice.
COMPLAINT RESOLUTION - STATE HEARING INFORMATION DCSS 0642 (05/19/08)

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