Form Il444-3455 - Child Care Application - Illinois Department Of Human Services

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State of Illinois
Department of Human Services - Bureau of Child Care and Development
Parent/Guardian Name:
The State of Illinois helps income eligible families pay for their child care services while they work or go to school, training and other work-
related activities. To apply please read the following pages carefully and then submit your completed application to your local Child Care
Resource and Referral (CCR&R) or child care center/home if they have a contract with IDHS to provide child care assistance. If you have
any questions about your eligibility or if you need help completing this form, call your local CCR&R. To find your local CCR&R go to http://
or call 1-877-202-4453 (toll-free).
Please be sure that all the information is complete before sending in your application:
The application is filled out clearly in blue or black ink.
All questions on the application are completed. If the section or question does not apply, please write "n/a" in the box to show the question was not missed.
Complete this form based on your current information. Inform the CCR&R or Site provider if any information changes in the future.
The parent/guardian's name is listed at the top of each page of the application.
The application is signed by the client (parent) and child care provider (pages 13 & 14).
Social security numbers are listed clearly or "n/a" is listed in the box. Social security numbers are not required for parents or children but they are used
to gather information to help determine your eligibility for child care assistance. Providers MUST list their valid tax identification
number (SSN, FEIN, Gov't unit code) or IDHS Provider Registration Number. All information is confidential and will not be shared
with anyone.
All Family Information is complete in section 3 of the application including information about your children's immigration status.
Children can get assistance regardless of their immigration status, but IDHS is required to ask for this information. This information
will not be shared with anyone. Your child's alien registration number must be listed if they have one.
All persons other than the applicant and the second parent living in the household are listed in section 3 (page 6).
If working, at least one of the following is attached to verify your employment and the employment of everyone listed in your family
size that is 19 years of age or older:
* Copies of your last two (2) paycheck stubs, or (if you have not been working long enough to get two paychecks).
* A letter from your employer or an employment verification form listing the following:
* The date you started working.
* The amount of money you are paid.
* Your typical work schedule, including the total number of hours you work per week.
* Your employer's address and phone number.
* Your employer's signature, or
* Verification of your self-employment. This can include:
* A copy of your most recent Federal Income tax return (IRS 1040) and all schedules and attachments.
* A copy of your quarterly estimated taxes.
* A listing of all business income and expenses for the last 30 days. This can be reported on your
own form or on a Self-Employment form which can be downloaded at:
Library/27897/documents/Forms/IL444-2790.pdf or requested from
your local CCR&R. When reporting income and expenses, all receipts, invoices, or other documentation
must be attached to verify all information.
If in school, ALL of the following are attached:
* Copies of your official school schedule.
* Copies of your most recent report card showing your cumulative grade point average (GPA).
You have made a copy of your application for your records. You understand if you send original check stubs or other documents
that they will not be returned.
All jobs and income information for BOTH parents have been reported on pages 3 and 5 and documentation is attached.
You understand that if any questions are left blank or if any attachments are missing, your application will be returned to you as incomplete.
This may cause a delay in approval for Child Care Assistance Program payments.
You also understand that all of the information you submit will be verified using State and/or local databases and the internet. If any inconsistencies
are discovered, your application may be delayed or your participation in the Child Care Assistance Program may be denied.
IL444-3455 (R-6-11)
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