Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 14

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State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE APPLICATION

Parent/Guardian Name:

SECTION 8 - PARENT/GUARDIAN CERTIFICATION

After reading each of the following statements, I certify that:

I understand that I am responsible for paying a share of my child care costs (parent co-payment) to my child care provider and that failure to do so

may result in the loss of my child care provider.

I understand that my eligibility will be redetermined every six (6) months or as needed.

The child(ren) is/are current on all immunizations and verification is on file with the child care provider.

A review of each facility/home has been completed and I agree that it is a safe environment.

I have given written notification to each child care provider if I want anyone other than myself to pick up the child(ren).

An emergency phone number and written consent for medical care and for dispensing prescription medication has been given to each child care

provider.

The name of the family physician is on file with each child care provider.

I am responsible for the selection of the child care providers for my child(ren).

I will report any change in child care arrangements, employment or family size, within 10 days. Failure to report changes in a timely manner may

result in an overpayment which I will have to pay back and/or loss of child care benefits.

I understand that I must be working or attending and IDHS approved education, training, or other work related activity in order to be eligible to

receive child care benefits.

I understand the information provided will be checked using State and other databases, and if inconsistencies are discovered, the processing of my

application may be delayed or denied.

I understand that deliberately providing an incorrect/fictitious Social Security number or withholding the Social Security number

information in order to defraud the State of Illinois will cause me to be prosecuted to the fullest extent of the Law.

The information provided will be disclosed only for administrative purposes and that I may be required to verify the information that I have provided.

I understand that I have the right to appeal and to have a fair hearing of a grievance.

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.

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.

Parent/Guardian's Signature:

Date:

Other Parent/Guardian's Signature:

Date:

IL444-3455 (R-6-11)

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