Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 11
Download a blank fillable Form Il444-3455 - Child Care Application - Illinois Department Of Human Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Il444-3455 - Child Care Application - Illinois Department Of Human Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE APPLICATION
Parent/Guardian Name:
SECTION 6 - CHILD CARE PROVIDER INFORMATION
To be completed by the Provider (Please print clearly in blue or black ink).
Parents or stepparents cannot be paid to provide child care for any children in the home.
Providers must be at least 18 years of age and clear required background checks.
Name of Child Care Provider
If you are a Day Care Center, Corporate Name
Address
Apartment Number
City
State
Zip Code
Mailing Address, if different than above:
County
Phone Number
Fax Number
E-mail
Date of Birth (MM/DD/YYYY) (Not required for Centers and Licensed Providers)
Month:
Day:
Year:
Social Security Number
(Individual or sole proprietor)
Provider Must Complete One:
Note: Read the instructions included with
FEIN (Corporation,
the W-9 form for information on these
partnership or sole proprietor)
options.
If you have already registered as a
Gov't Unit Code
provider for this program, list only your
(Public school or park district)
registration number.
IDHS Provider Registration
Number
Child care providers are considered to be self-employed and taxes cannot be deducted from IDHS payments. This income is
taxable and must be reported on tax documents. The Office of the Comptroller sends out a 1099 tax information form after
each calendar year to all individual providers that earn $600 or more a calendar year.
Enter date the child care provider recently began or will begin caring for children: (MM/DD/YYYY)
Yes
No
Have you been approved for the Illinois Quality Counts Quality Rating System (QRS)?
Yes
No
Are you an employee of the Illinois Department of Human Services or any other State agency?
Have you ever been convicted of anything other than a minor traffic violation?
Yes
No
If yes, please explain:
CHILD CARE COLLABORATIONS
Are you an IDHS approved Child Care Collaboration?
Check all that apply:
Yes
No
Head Start
ISBE Pre-K
Are any of the children in this family enrolled as a collaboration child?
How long is your program?
9 Mo
12 Mo
Other
IL444-3455 (R-6-11)
Page 11 of 17
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal