Family Financial Statement (DS 1235A)
The Family Financial Statement (FFS) is used to report income and family size information to the Department for the purpose of assessing a monthly parental fee. Form is available in English | Spanish. The monthly parental fee shall be assessed beginning 60 days from the date of the consumer’s placement into 24-hour out-of-home care. Parents are required to provide to the Department a completed FFS for both parents within 30 days of the Department’s request, along with documentation of income. The Department shall assess a monthly maximum fee if parents do not provide income and family size documentation within the 30 days of the Department request. Parents who are unable to comply with income reporting requirements are urged to contact the program staff at (800) 862-0007 (Monday through Friday 8:00 a.m. – 5:00 p.m.).
Home Leave Credits (DS1214)
Parents who remove their child from the 24-hour out-of-home care services for a home visit for six or more consecutive hours during a 24-hour period, shall be entitled to a credit equal to one day of the monthly parental fee. A credit shall be calculated by multiplying the parents’ monthly parental fee by 12 and dividing that number by the number of days in the year. Credits must be requested within 60 days after the day when the child was returned to a facility after the qualified home visit. Parents may submit a request for Home Leave Credits (HLC) in writing using form DS 1214 English | Spanish. The information on this form must include the dates and times the child left and returned to the facility, and must be signed by a facility representative certifying the leave(s).
Parental Fee Appeals
Parents who disagree with the fee assessment, or the amount of Home Leave Credits granted may appeal within 30 days of the Department’s notification of the amount of the fee, or Home Leave Credits requested. Parents appealing must do so in writing addressed to the Department of Developmental Services / Client Financial Services Section, 1215 O Street (MS 10-30), CA 95814. Appeals must be submitted within 30 days of the Department’s fee notification letter, or decision on Home Leave Credit requests. Appeals may only consider the family income used to set the fee, or the amount of the Home Leave Credit.
Payments
You may pay your monthly parental fee by check, money order, or credit card (VISA/MasterCard only).Mail your monthly fee by check or money order to our contact address
Department of Developmental Services
Client Financial Services Section
1215 O Street (MS 10-30)
Sacramento, CA 95814
Paying Your Monthly Fee by Credit Card
If you want to make a payment by credit card, you can contact us at (800) 862-0007, Monday through Friday from 8:00 a.m. – 5:00 p.m. to make a payment over the phone.
Frequently Asked Questions
1. Who is eligible for the Parental Fee Program?
2. What information is used to determine the monthly fee?
- Both parent’s annual gross income
- 50% of step-parent’s income
- Household size
3. How is the fee calculated?
- Parents with annual gross income below 201% of the Federal Poverty Level* (FPL) will be assessed a $0 fee.
- Parents with annual gross income at or above 201% of FPL will be assessed a fee based on a percentage of income as shown in the fee schedule.
For example, a family of 4 at different income levels will have their fee set as follows:
Annual gross income of $45,000 is below 201% of FPL Monthly Fee= $0
Annual gross income of $70,000 is between 201%-300% of FPL. Monthly Fee will be calculated using 3% of annual gross income and dividing this amount by 12 months.
$70,000 x 3% = $2,100/12 months = Monthly Fee of $175
Annual gross income of $95,000 is between 301%-400% of FPL. Monthly Fee will be calculated using 4% of annual gross income and dividing this amount by 12 months.
$95,000 x 4% = $3,800/12 months = Monthly Fee of $317
Annual gross income of $150,000 is between 401%-500% of FPL. Monthly Fee will be calculated using 5% of annual gross income and dividing this amount by 12 months.
$150,000 x 5% = $7,500/12 = Monthly Fee of $625
Annual gross income of $200,000 is above 501% of FPL. Monthly Fee will be calculated using 6% of annual gross income and dividing this amount by 12 months.
$200,000 x 6% = $12,000/12 = Monthly Fee of $1000
4. What documents are required for parental fee assessments?
- Three successive pay stubs for both parents issued within the last 60 days.
- Employer provided earnings statement issued within the last 60 days
- Unemployment, Social Security, Disability, Workers Compensation, or other Public Aid requires copy of award letter issued within the last 60 days or documented proof of the amount of the monthly award received.
- Child support and alimony income require proof of support amount received.
5. When can parents file an appeal?
Appeals can be filed for the following reasons:
- When you feel the Department made a mistake in calculating your parental fee amount.
- When you feel the Department made a mistake in denying or in calculating the amount of home leave credits.
- When you feel the Department made a mistake in denying your request for temporary fee waiver.
6. What happens if parents do not send all the information needed to determine the parental fee?
Parents who do not complete and return the FFS with the income documentation requested within 30 days of the Department’s request, will be assessed the maximum fee allowable. Maximum fees are calculated using the most recent data available from the United States Department of Agriculture’s survey on the cost of raising a child in the west region. Maximum fees will be calculated based on the consumer’s age group.
Maximum Fees** | |
Age Groups |
Maximum Fee |
0-2 | $1,723 |
3-5 | $1,723 |
6-8 | $1,691 |
9-11 | $1,798 |
12-14 | $1,826 |
15-17 | $2,013 |
**USDA Maximum Cost of Caring for a Child.
Parents who later provide income and family size information necessary to assess their calculated fee will have their fee adjusted accordingly.
7.What happens when a parent’s income or household size changes after the parental fee was assessed?
8. What are Home Leave Credits?
These are daily credits granted by Department to parents who take their child out of the 24-hour care facility for a period of no less than 6 consecutive hours in a 24-hour period. The credits accumulated each month are used to reduce the amount of the monthly fee due from parents. In order to qualify for Home Leave Credits (HLCs), the following requirements must be met:
- Parents need to complete DS1214 form. The HLC form is available on DDS website at https://www.dds.ca.gov/wp-content/uploads/2023/08/DS1214-New-HLC-Form-1.pdf.
- The HLC from must be signed by home care facility staff certifying the dates and times of the child is away from the care facility.
- The HLC request must be received by DDS within 60 days from the date of parents’ visit.
HLC requests received and approved by the 15th of each month will be posted in the following month’s statement.
9. How can parents pay their Parental Fee?
Parents can pay their parental fee with check or money order. Payments can be mailed to:
Department of Developmental Services, Client Financial Services, 1215 O St, MS 10-30, Sacramento, CA 95814
Parents can also make payments using a credit card (Visa/MasterCard only) by phone at (800) 862-0007, Monday through Friday from 8:00 a.m. – 5:00 p.m. to make a payment over the phone.
10. Who can parents call for other Parental Fee Program questions?
Parents can contact Parental Fee Program staff at 1-800-862-0007, Monday through Friday from 8:00 a.m. – 5:00 p.m. Parents can also email the program at ddsparentalfee@dds.ca.gov.
Last modified: May 15, 2025