Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 2
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17State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE APPLICATION
Important Notice: The sooner your application is
Parent/Guardian Name:
submitted, the sooner benefits can be determined.
Return your completed application to:
PLEASE TYPE OR PRINT CLEARLY IN BLUE OR BLACK INK. Please read the attached checklist before completing this
form. (Este formulario está disponible en español. For the Spanish version go to
)
SECTION I - PARENT/GUARDIAN INFORMATION
Parent/Guardian First Name:
M.I.
Last Name:
Social Security Number (Optional)*
TANF, Food Stamps (SNAP), or Medical Assistance case number, if applicable
County
Home Address (required)
Apt. #
City
State
Zip Code
City
Mailing address, if different than above.
State
Zip Code
Home Telephone Number
Mobile Telephone Number
Best time to call
Another number where you can be reached
E-mail Address
Parent/Guardian Date of Birth (Include Month/Day/Year)
Male
Female
Check one:
OR
Other:
English
Spanish
Polish
Chinese
Language:
* Social Security Numbers are not required at this time for child care eligibility and eligibility will not be denied due to your
failure to provide this information. Social Security Numbers are used to assemble research data sets that do not identify
individuals and to verify income. Social Security Numbers will be disclosed for administrative purposes only and are
confidential.
Do you have more than one child care provider for this
Do any of your other children attend Head Start, Pre-K or Child
application?
Care at a provider not on this application?
Yes
No
Yes
No
You must complete a separate child care arrangement Section 4 (page 8) for each provider.
If yes, list all child care provider names and registration
List all other child care provider(s) such as Head Start, Pre-K or
numbers (if assigned) you seek assistance in paying:
Child Care at a provider not on this application.
IL444-3455 (R-6-11)
Page 2 of 17
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