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LCR001 (12/01) E-MAIL ADDRESS FOR AGENCY USE ONLY COMPLAINANT'S NAME (Last) (First) STATE ZIP CODE TELEPHONE NUMBER CITY COUNTY YOU ARE COMPLAINING ABOUT COMPLAINANT'S MAILING ADDRESS DATE This request was taken (check one): in person by telephone by letter LCSA REPRESENTATIVE'S SIGNATURE LCSA REPRESENTATIVE'S NAME (Print) DATE COMPLAINANT'S SIGNATURE --THIS SECTION TO BE COMPLETED BY LCSA REPRESENTATIVE-- LCSA CASE NUMBER LCSA DATE OF RECEIPT REQUEST FOR COMPLAINT RESOLUTION FAX NUMBER DESCRIBE YOUR COMPLAINT: (If you need more space, you may continue on another page and attach it to this form.) To request complaint resolution, you can either mail or deliver this form to the local child support agency you are complaining about, or call the local child support agency to file your complaint verbally. ---PAGE BREAK--- RIGHT TO A STATE HEARING: 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. 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. You can request a State Hearing in writing by sending a Request for State Hearing form (SH001) to the State Hearing Office, or you can call the State Hearing Office toll free at 1-[PHONE REDACTED]. OMBUDSPERSON SERVICES: 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 you have a complaint against a local child support agency or the Franchise Tax Board 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 reverse side of this form, or you can call the local child support agency. RIGHT TO COMPLAINT RESOLUTION: 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. 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. Complaints of alleged discourteous treatment by a local child support agency employee, unless such conduct resulted in a hearable action or inaction. IMPORTANT: The following issues cannot be heard at a State Hearing: The local child support agency's decision to close a child support case. State Hearings will only be granted for the following issues: 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, 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. An application for child support has been denied or has not been acted upon within the required time frame. IMPORTANT: The Ombudsperson cannot represent you at the State Hearing or give you legal advice. 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. 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. Child support issues that must be addressed by motion, order to show cause, or appeal in a court.