Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 3

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.

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE APPLICATION

Parent/Guardian Name:

WORK INFORMATION -

If you are working more than one job, you MUST tell us about all your jobs even if you

Number of jobs currently working

don't need child care for that job. Photocopy this page and complete a separate work information and work schedule

section for each job you have.

First Employer/Company Name

Job Title

City

Zip Code

Address

State

Work Telephone Number

Ext.

Date you started this job:

per month OR

I earn before deductions (complete one):

per hour OR

per year

I get paid (check one)

Number of hours usually worked at

Number of days usually worked at this

every day

every week

this job each week

job each week

every two weeks

twice per month

once per month

other (please explain)

Travel time from the child care provider to work:

Do you use public transportation?

WORK SCHEDULE: If your schedule varies, provide an example of your schedule.

MON

TUES

WED

THURS

FRI

SAT

SUN

FROM

If your schedule varies, please explain how (you may send additional documentation to verify, see Frequently Asked Questions #11 on page 16 of this application):

Second Employer/Company Name