Form Cfs 718E PDF Details

Form Cfs 718E is a form used to apply for disability benefits. The form can be used by individuals who are unable to work because of a disability, and by their representatives. The form is used to apply for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). Benefits may be available if you have a physical or mental impairment that prevents you from working, and meets the Social Security Administration's definition of disability. You can use Form Cfs 718E to apply for benefits online, or you can print out the form and mail it in. Be sure to include all required information, and provide proof of your disability if requested. The SSA will review your application and let you know if you are eligible for benefits. If you have any questions about completing Form Cfs 718E, or about applying for disability benefits, please contact the SSA toll-free at 1-800-772-1213 Monday through Friday from 7:00 am to 7:00 pm ET. We wish you the best of luck in obtaining

QuestionAnswer
Form NameForm Cfs 718E
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesCANTS, CFS, printable exemption page for chapter 7 champaign il, ISP

Form Preview Example

CFS 718-E

 

Illinois Department of Children and Family Services

Rev 12/2013

 

AUTHORIZATION FOR BACKGROUND CHECK

 

 

READ INSTRUCTIONS ON REVERSE SIDE AND PRINT ALL INFORMATION

 

 

FOR EMPLOYEES/VOLUNTEERS OF CHILD CARE FACILITIES

 

 

 

 

 

1

Employee

 

Day Care Center

Day Care Agency

Or

of:

Group Home

Child Welfare Agency

 

 

Volunteer

 

Child Care Institution/Maternity Center

Youth Emergency Shelter

 

 

 

 

 

PERSONAL INFORMATION

2

 

 

 

 

 

 

 

 

 

 

 

Last Name/First Name/Middle Initial

 

 

 

 

 

 

 

 

 

 

Social Security or ITIN Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ __ __ - __ __ - __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden and/or Any Names Formerly Used (Last/First/Middle Initial)

 

 

 

 

 

Telephone (Including Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

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-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CURRENT ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

Have you lived outside of Illinois in the past 3 years?

 

Yes

 

 

No

Street/Apt.#:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all previous addresses for the past five (5) years including Illinois.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Street/Apt.#/City/County/State/Zip Code)

 

 

 

 

Dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From/To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

Age

Place of Birth

Citizenship (Country)

 

 

Sex

 

Height

 

Weight

Hair

 

 

Eyes

 

Skin

 

Race

 

 

(Month/Date/Year)

 

 

 

(City and State)

USA

 

 

M

 

Ft. In.

 

 

(lbs.)

(color)

 

 

(color)

 

Tone

 

 

 

-

 

 

-

 

 

 

 

 

 

 

Other, Specify

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION /CERTIFICATION

3

Have you ever been convicted of a criminal offense, other than a minor traffic violation?

Yes

No

Have you ever been indicated as perpetrator in a child abuse/neglect investigation?

Yes

No

I certify that I have read and understood the Authorization/Certification box on the back page of this form.

SIGNATURE

 

DATE

Parent/Guardian Signature (if applicable)

 

 

DATE

BACKGROUND RESULTS

Sex Offender Clearance:

CANTS Clearance:

Illinois State Police Clearance:

FBI Clearance:

Transfer Clearances: SO/CANTS:

 

ISP:

 

 

 

 

FOR CENTRAL OFFICE OF LICENSING USE

SID# ClearRecord

BC-03 Registered:

FBI Sent Out:

4

TO BE COMPLETED BY EMPLOYER

This authorization form will not be processed without completion of this section.

Name of Facility Contact

Date Fingerprinted:

Full Name of Facility

Provider ID #

Street Address:

 

Phone Number of Facility Contact

City

 

IL ZIP:

 

 

 

 

()

INSTRUCTIONS FOR COMPLETION OF

CFS 718-E - AUTHORIZATION FOR BACKGROUND CHECK

WHO SHOULD USE THIS FORM: This form must be completed by employees and volunteers, age 13 or older, who work in a day care center, day care agency, group home, child welfare agency, child care institution/maternity center or youth emergency shelter. Employees of day care homes, foster care homes and group day care homes are to use form CFS 718. The Parent or Guardian’s signature is required if background check is for a minor.

Do not send a request for a Child Abuse/Neglect Tracking System (CANTS)

check to Central Licensing until the person has been fingerprinted.

SECTIONS 1, 2 AND 3 –- COMPLETION OF IDENTIFICATION INFORMATION

Employer must instruct every person subject to a background check to complete the first three sections identifying the type of facility and what role they will have at the facility and all personal information. All identifying information must be accurate and complete.

PRINT ALL INFORMATION

Name:

Social Security or ITIN No.

Address:

Race:

Current and all former names used by the individual must be included. If no other names, write “none.”

THIS FORM WILL NOT BE PROCESSED WITHOUT A COMPLETE SOCIAL SECURITY OR INDIVIDUAL TAXPAYER IDENTIFICATION (ITIN) NUMBER

Current and all addresses, including county, where the person has lived in the past five years (If outside of Illinois, check appropriate box)

Enter all codes that apply

BL/AA

Black or African American

ASIAN

Asian

HISP ORG

Indicate whether the individual is of Hispanic origin

NH/PI

Native Hawaiian or Other Pacific Islander

WHITE

White

UNDET

Undetermined

AI/AN

American Indian or Alaskan Native

 

 

Each Person “must” answer the questions “Have you ever been convicted of a criminal offense, other than minor traffic violation?”

The person completing the identification information must sign and date page 1 of the authorization form.

SECTION 4 - EMPLOYER

The Authorization for Background Check must be submitted to the employer for completion of Section 4 and to check the form for completeness and accuracy before the employee is fingerprinted.

Employer must complete the following:

Name of Facility

Name of facility where employed. Use the full name which appears on the license application or the license.

 

(DO NOT USE ACRONYMS)

Street/City/Zip

The site of licensed facility where person is employed.

Provider ID #

The Provider ID # is required. (The number which appears on the license certificate for the facility.)

AUTHORIZATION/CERTIFICATION

I authorize the Illinois Department of Children and Family Services to conduct an investigation to determine whether I have ever been charged with a crime and, if so, the disposition of those charges. I authorize the Department to request information and assistance from the U.S. Justice Department and the Illinois Department of Law Enforcement in the conduct of this investigation. I authorize the Department to periodically search the Child Abuse and Neglect Tracking System to determine whether I have been a perpetrator of an “indicated” incident of child abuse or neglect pursuant to the Abused and Neglected Child Reporting Act. The child abuse and neglect background check and the criminal history investigation may be used for considering an application for license, current or prospective employment, or service as a volunteer in a child care facility. Persons 13-17 years of age signing this form authorize a search of CANTS and LEADS only and are not subject to fingerprinting.

I understand that information obtained as a result of my authorizing this investigation is confidential but may be shared with my employer, prospective employer or with authorized licensing staff in accordance with applicable state and federal law and DCFS Regulations. I further certify that the information provided on this form is true and correct. I acknowledge that falsification of any information provided above and/or the results of the background check may be full and sufficient grounds to deny the application for licensure or may result in the termination of my employment.

Should you feel that the information on your Illinois State Police record or Federal Bureau of Investigation record is incorrect you may visit: http://www.ilga.gov/commission/jcar/admincode/020/02001210sections.html for the ISP and http://www.fbi.gov for FBI.

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