Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 7
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17State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE APPLICATION
Parent/Guardian Name:
I need child care assistance for the following children:
Date
Social
Ethnic
First Name
Last Name
M/F
of Birth
Security #
Origin *
Yes
No
Yes
No Relationship to Client:
U.S. Citizen**
Ward of State?
Date
Social
Ethnic
First Name
Last Name
M/F
of Birth
Security #
Origin *
Yes
No
Yes
No Relationship to Client:
U.S. Citizen**
Ward of State?
Date
Social
Ethnic
First Name
Last Name
M/F
of Birth
Security #
Origin *
Yes
No
Yes
No Relationship to Client:
U.S. Citizen**
Ward of State?
Date
Social
Ethnic
First Name
Last Name
M/F
of Birth
Security #
Origin *
Yes
No
Yes
No Relationship to Client:
U.S. Citizen**
Ward of State?
Date
Social
Ethnic
First Name
Last Name
M/F
of Birth
Security #
Origin *
U.S. Citizen**
Yes
No
Ward of State?
Yes
No Relationship to Client:
*For each child's Ethnic Origin, list all numbers below that apply: (Required for Federal Reporting) 1 - White 2 - Black or African
American 3 - Hispanic or Latino (Persons declaring Hispanic ethnicity should also list their race, for example, "3-1", "3-2", "3-5")
4 - Asian 5 - American Indian or Alaskan Native 6 - Native Hawaiian - or Pacific Islander.
** If any of the children are not citizens, provide alien registration documentation if you have it.
List all other family members (not already listed in the application) counted in your family size:
SOCIAL SECURITY
DATE OF
RELATIONSHIP
FIRST NAME
LAST NAME
NUMBER (Optional)
BIRTH
TO APPLICANT
IL444-3455 (R-6-11)
Page 7 of 17
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