This government document is issued by Department of Child Support Services for use in California
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https://www.google.com/url?client=internal-element-cse&cx=001779225245372747843:3a1xdp1oi78&q=https://childsupport.ca.gov/wp-content/uploads/sites/252/Employers/Request-and-Notice-of-Hearing-Regarding-Health-Insurance-Assignment-Form-8.19.19_ADA_actual.pdf&sa=U&ved=2ahUKEwiVsKSfmfbxAhXFAxAIHWDLC-I4FBAWMAF6BAgHEAE&usg=AOvVaw13trdDagWL3WluSRAl_IXd