How to Fill Out and Submit California DCSS 0114: Termination of Benefits

The California DCSS 0114 form, officially the Termination of Benefits/Employment Notice, is a one-page notice that an employer sends to the local child support agency (LCSA) when an employee subject to a child support income withholding order leaves the job, loses employer-sponsored health coverage, or both.¹ Filing it keeps wage withholding and medical support from lapsing while the parent transitions.

One quick boundary before the walkthrough: if you are a parent, not an employer, and you need to file case information with the court, the form you want is FL-191 (the Child Support Case Registry Form), not DCSS 0114.² DCSS 0114 is strictly an employer obligation and goes to the child support agency, not the court.

When You Have to File It

File DCSS 0114 whenever one of three things happens to an employee who has an active child support income withholding order or a National Medical Support Notice on file with you:

The employee’s employment ends.
The employee’s employer-provided health insurance ends.
Both happen together.

The most common trigger is a resignation or layoff. But the form also applies when the employee stays on payroll and only the health coverage changes, for example if you switch to a plan that no longer covers dependents. In that case you would check “Health Benefits” only and leave the employment section blank.¹

File promptly. Federal child support enforcement guidance directs employers to notify the issuing agency as soon as an employee separates so collection does not stop while the parent moves to a new job.³

What to Gather Before You Start

Pull these details together first. Every field on the form ties back to something the agency needs to reroute enforcement:

The employee’s full name, last known home address, phone number, date of birth, and Social Security number.
The exact date employment ended, benefits ended, or both, and the reason for each.
Whether the employee is eligible for COBRA, and if so, the date coverage runs through.
The new employer’s name, address, and phone number, if you know where the employee is going.
The name, title, and signature of the person certifying the form for the employer.

The form also has administrative fields at the bottom for employee name, employer name, county, phone number, and participant number. Pull those identifiers straight from the original withholding order or National Medical Support Notice so the agency can match your submission to the right case.¹

Filling Out Each Section

Termination Type

At the top, check one of three boxes: Employment, Health Benefits, or Both. This single choice tells the agency whether to stop the income withholding order, update medical support, or do both. Check the wrong box and the agency may keep sending withholding orders to your payroll after the employee is gone.

Benefits Information

Enter the date health benefits ended and the reason. Indicate whether COBRA coverage is available, and if so, the date it runs through. If the lapse is temporary, say because the employee is moving between plans, mark “Temporary Lapse” and enter the date coverage is expected to resume. If coverage is gone for good, mark “Permanent Termination.”¹

Employment Information

Enter the date employment ended and the reason. The form also asks whether the employee is subject to rehire. Answering “Yes” tells the agency it may make sense to keep the case on a short monitoring cycle rather than immediately chase a new employer.

Employee Contact and New Employer

Fill in the employee’s last known home address, phone number, date of birth, and Social Security number. If you know the next employer, include the name, address, and phone. Leaving those new-employer fields blank is fine when you genuinely don’t know, because the agency has other tools to locate the parent, but supplying the information speeds enforcement considerably.

Certification and Signature

The form carries a declaration under penalty of perjury under California law. The signer must print their name, give their title, date the form, and sign. Treat this as substantive, not a formality. A false statement here carries the same legal weight as lying under oath.¹

Where to Get the Form

The California Department of Child Support Services hosts a downloadable PDF of DCSS 0114 on its employer forms page.⁴ You may already have one in hand, since the form is often included in the National Medical Support Notice packet sent to employers at the start of a case. For a fresh copy, the DCSS website is the fastest source.

Where to Send It

Send the completed form to the local child support agency that issued the original withholding order or medical support notice. The agency’s name, address, and contact information appear on the withholding order. Most LCSAs accept the form by mail or fax, and some counties also accept scanned submissions by email. If you are unsure which office handles the case, use the county office locator on the DCSS website.

What Happens After You Submit

Once the LCSA processes the form, it updates the case in California’s child support enforcement system. If you provided new-employer information, the agency sends a new income withholding order to that employer. If you did not, the agency uses state new-hire reporting data and the Federal Parent Locator Service to find the employee’s next job, and case data is shared with the Federal Case Registry so enforcement can follow the parent across state lines when needed.⁵ On the benefits side, reporting a temporary lapse rather than a permanent termination helps the agency avoid unnecessary enforcement action while coverage is being restored.

Mistakes That Cause Rejections and Delays

The form is short, but a few errors come up over and over:

Checking the wrong termination type. Marking “Employment” when only benefits ended, or the reverse, sends the agency down the wrong enforcement path.
Leaving off the participant number. That number links the form to the correct case; without it, the submission may not match any active case and sits in a processing queue.
Leaving COBRA status blank. The agency needs to know whether the children can continue coverage, and skipping the field forces a follow-up that delays medical support decisions.
No signature. Because the certification is made under penalty of perjury, an unsigned form is invalid and the agency will reject it.

Before you send it, check the employee’s Social Security number against payroll. A single transposed digit can match the wrong case, or none at all.

1
California Department of Child Support Services. Termination of Benefits/Employment Notice
2
California Courts. Rule 5.330 Procedures for Child Support Case Registry Form
3
Administration for Children and Families. Reporting Employee Terminations for Private Employers and Federal Agencies
4
California Department of Child Support Services. Employer Forms
5
California Legislative Information. California Code Family Code FAM 17391