Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 13

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State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE APPLICATION

Parent/Guardian Name:

SECTION 7 - CHILD CARE PROVIDER CERTIFICATION

After reading each of the following statements regarding child care standards, I certify that:

Parents will have unrestricted access to their children at all times.

All state and local fire, health and safety codes have been followed and will be maintained.

All child care providers/staff will have a physical examination no more than two years old and a TB skin test documented and on file in

the facility/home within 90 days of the signature date on this form. The TB skin test is to be no earlier than the date the provider/staff

began providing child care services.

All cleaning agents, poisons and other hazardous materials are stored in an area inaccessible to the child(ren).

There are no firearms or ammunition in the home OR any firearms or ammunition in the home are stored in a locked cabinet or locked storage at all

times.

First aid supplies are readily available.

There will be no corporal punishment.

The children will be provided developmentally appropriate play and physical activities daily.

The children will be supervised (indoors and outdoors) at all times.

The children will be provided nutritional meals/snacks daily based on the number of hours in care.

I have not been responsible, and if I am a home provider, no one living in my household age 13 and older has been responsible, for the abuse or

neglect of children or any acts of sexual molestation or sexual exploitation of children. I authorize the Dept. of Children and Family Services to check

the Child Abuse and Neglect Tracking System (CANTS) and the Sex Offender Registry (SOR) to confirm this information for the Department of

Human Services.

I and members of my household may need to complete an Authorization for Background Check form. If required, the CCR&R will mail this form

with instructions on how to complete it.

After reading each of the following statements regarding child care assistance program policies, I understand:

That if I am a home child care provider, I will report any new person(s) living in my household within 10 days.

The information provided will be checked using State databases.

understand the information provided will be disclosed only for administrative purposes and that I may be required to verify the information, but is

also subject to release under FOIA.

I cannot be paid until I complete a W-9 form and I am certified by the Office of the Comptroller.

I am responsible for collecting a co-payment from each family and that the co-payment will be deducted from the payment I receive from IDHS.

The State is required to make payment deductions for all home child care providers in accordance with the Service Employees International Union

(SEIU) contract.

The State is not liable for payment of child care services provided prior to the date of an approval notice issued by the State.

If I am a child care center provider, licensed home, or group home, I will maintain, for a minimum of five (5) years from the date of payment, daily

attendance records to fully document the extent of services provided and agree to make all records and supporting documentation relevant to the

services billed herein available to any and all authorized Department representatives and Federal authorities.

Failure to maintain adequate records shall establish a presumption in favor of the State for any funds paid by the State for which adequate

documentation is not available to support disbursement.

In order to be considered exempt from DCFS licensing, I can care for

no more than three children during any given day, including my own children,

unless all children are from the same household.

If not licensed by DCFS, copies of my Social Security Card and current driver's license, State ID card, or military ID are included. In order to be

current, the driver's license or ID must list my current address.

I declare under penalty of perjury that I have read all statements on this form and the information I give is true, correct and complete to the best of my

knowledge. I understand that giving false information or failing to provide correct information can also result in an overpayment which I will have to

pay back and could result in my prosecution for fraud.

That the rates charged to the State of Illinois do not exceed the maximum allowed by the State and do not exceed those charged to the general

public for similar services. This includes discounts such as multiple child discounts, staff discounts, full-week discounts, per-pay discounts, and

sliding fee scales.

I certify that the hours of child care do not include hours the child is in school.

That deliberately providing an incorrect/fictitious Social Security number in order to defraud the State of Illinois will cause me to be prosecuted to the

fullest extent of the law.

My signature is my consent and authorization for information to be released to the Illinois Department of Human Services or its agents that may

establish my eligibility or my continued eligibility for the Child Care Program.

By signing and dating this document I certify that I have read and understand all the statements listed above. I certify that the statements as they

are listed are true and that the information provided on this application is true, correct and complete.

Child Care Provider Signature:

Date:

IL444-3455 (R-6-11)

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