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- Click ‘Get Form’ to open the dcss 0054 in the editor.
- Begin by filling in your County and Phone number at the top of the form. Next, enter the LCSA Case Number and details of the Noncustodial Parent including their full name and address.
- In Section I, indicate whether health insurance is currently provided by selecting 'Yes' or 'No'. If 'Yes', provide details about the health insurance company, including its address and your policy number.
- Complete all relevant fields regarding premium amounts, payment frequency, and dependent coverage under health, dental, and vision insurance. Ensure you check all applicable boxes for services covered.
- In Section II, answer questions regarding the other parent's insurance coverage similarly. Fill out any additional information as required.
- Finally, review your entries for accuracy before signing and dating the form at the bottom. Attach any additional sheets if necessary.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2005 | 4.9 Satisfied (410 Votes) |
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