Form Il444 4469 PDF Details

In the world of child care within Illinois, the IL444 4469 form plays a pivotal role in ensuring that child care providers are compensated fairly by the State's Department of Human Services. Requiring detailed information such as provider name, address, the type of care given (whether it's a licensed center, home, licensed-exempt center, or group home), and crucially, the rates charged for different age groups and types of care, this form forms the cornerstone for rate certification for providers. It's not only a tool for communicating rates to the Child Care Resource and Referral Agencies (CCR&R) but also serves as a declaration by providers that their charges to the state do not surpass those levied on the general public for similar services. With stringent instructions to attach a separate rate sheet if needed, and a certification that information provided must be true and accurate under penalty of fraud, the form underscores the seriousness with which the state treats child care services. Providers are asked about discounts they offer, ensuring that the state's payments reflect the true cost of care provided. It's essential that this form is completed accurately and returned to the relevant CCR&R, as listed in the document, highlighting a well-structured system aimed at fair compensation in child care services across Illinois.

QuestionAnswer
Form NameForm Il444 4469
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesHancock, Sangamon, R-10-11, il444 4469

Form Preview Example

State of Illinois

Department of Human Services

Child Care Rate Certification Form

Please complete this form and return to your Child Care Resource and Referral Agency (CCR&R). A listing of the counties served by each CCR&R, their address and phone number is on the back of this page.

Child Care Provider Information

Name:

Doing Business As:

Address:

City, State, Zip:

Provider Social Security Number (SSN) or

Federal Employer Identification Number (FEIN):

County in which care is provided:

Phone Number:

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-Mail Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Care:

 

760 Licensed Center

 

762

Licensed Home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

761 Licensed-Exempt Center

763

Licensed Group Home

 

 

 

 

DCFS Day Care License Number:

 

 

 

 

 

 

 

(Not Foster Care License Number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License Expiration Date:

Hours of Operation: From

To

 

License Capacity:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day:

Night:

 

 

 

 

 

Extended:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daily Rates

 

 

 

 

 

 

 

 

 

Effective Date of Rates Below:

Check if you have a separate rate sheet. A copy of your rate sheet must be attached. This can be done to accomodate different rates.

Under Age 2

Age 2

Age 3 and Older

Full-Day Rate (5-12 hours per day)

Part-Day Rate (less than 5 hours per day)

School Age Rate (for centers only)

Do you have any discounts (such as multiple child discounts, staff discounts, full-week discounts, pre-pay discounts, or sliding fee scales)? If yes, list the type and amount of your discounts.

I certify that the information provided is true, correct, and complete. I also certify that the rates charged to the State of Illinois do not exceed the maximum allowed by the State and do not exceed the rates I charge to the general public for similar services. This includes discounts such as multiple child discounts, staff discounts, full-week discounts, pre-pay discounts, and sliding fee scales. I understand giving false information or failure to provide correct information can result in referral for prosecution for fraud.

Signature

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-4469 (R-5-12) Child Care Rate Certification Form

 

 

 

Printed by Authority of the State of Illinois P.O. #12-1386 6,200 copies

 

Page 1 of 2

State of Illinois

Department of Human Services

Child Care Rate Certification Form

IDHS Child Care Assistance Program - CCR&R List

Counties Served & CCR&R

Counties Served & CCR&R

 

 

 

 

Cook

Coles, Clark, Cumberland, Edgar, Moultrie & Shelby

 

Action for Children

Child Care Resource & Referral

 

Child Care Assistance Program

Eastern Illinois University

 

1340 S. Damen Ave.

600 Lincoln

 

Chicago, IL. 60608

Charleston, IL. 61920

 

(312) 823-1100

(800) 643-1026

 

 

 

 

Boone, Jo Daviess, Stephenson & Winnebago

Adams, Brown, Calhoun, Cass, Greene, Hancock, Jersey, Pike

 

YWCA Child Care Solutions

& Schuyler

 

Child Care Assistance Program

West Central Child Care Connection

 

4990 E. State St.

510 Maine, Room 610

 

Rockford, IL. 61108

P.O. Box 610

 

(815) 484-9448 or (800) 872-9780

Quincy, IL. 62306

 

 

(217) 222-2550

 

Carroll, DeKalb, Lee, McHenry, Ogle & Whiteside

 

 

 

Christian, Logan, Macoupin, Mason, Menard, Montgomery,

 

Community Coordinated Child Care (4-C)

 

155 N. Third St., Suite 300

Morgan, Sangamon & Scott

 

DeKalb, IL. 60115

Community Child Care Connection, Inc.

 

(800) 848-8727 Ex. 225

919 S. Spring St.

 

 

Springfield, IL. 62704

 

 

(217) 525-2805

 

Lake

 

YWCA of Lake County

 

 

Child Care Resource & Referral Service

Henderson, Henry, McDonough, Mercer, Knox, Rock Island

 

2133 Belvidere Rd.

& Warren

 

Waukegan, IL. 60085

Community Child Care Resource & Referral

 

(847) 662-6129

500 East 59th St.

 

 

Davenport, IA. 52807

 

DuPage & Kane

(800) 923-7844

 

YWCA Child Care Resource & Referral

 

 

Bond, Clinton, Madison, Monroe, Randolph. St. Clair

 

Child Care Assistance Program

 

55 E. North Ave.

& Washington

 

Glendale Heights, IL 60139

CHASI-Child Care Resource & Referral

 

(630) 790-8009

2133 Johnson Rd. Suite 100A

 

 

Granite City, IL. 62040

 

 

 

Grundy, Kankakee, Kendall & Will

(800) 847-6770

 

Child Care Resource & Referral

 

 

801 N. Larkin, Suite 202

Clay, Crawford, Edwards, Effingham, Fayette, Jasper,

 

Joliet, IL. 60435

Jefferson, Lawrence, Marion, Richland, Wabash & Wayne

 

 

 

(800) 641-4622

Project CHILD

 

 

 

 

Rend Lake College

 

 

 

Bureau, Fulton, LaSalle, Marshall, Peoria, Putnam, Stark,

P.O. Box 827

 

 

 

Tazewell & Woodford

Mt. Vernon, IL. 62864

 

 

 

SAL Child Care Connection

(800) 362-7257

 

 

 

3425 N. Dries Lane

 

 

 

 

Peoria, IL. 61604

DeWitt, Ford, Livingston & McLean

 

(800) 421-4371

Child Care Resource & Referral Network

 

 

207 W. Jefferson, Suite 301

 

Alexander, Franklin, Gallatin, Hamilton, Hardin, Jackson,

 

Bloomington, IL. 61701

 

Johnson, Massac, Perry, Pulaski, Pope, Saline, Union, White

(800) 437-8256

 

& Williamson

 

 

Child Care Resource & Referral

Champaign, Douglas, Iroquois, Macon, Piatt & Vermillion

 

John A. Logan College

Child Care Resource Service

 

Carterville, IL. 62918

Child Care Assistance Program

 

(800) 548-5563

314 Bevier Hall, 905 S. Goodwin

 

 

Urbana, IL. 61801

 

 

(800) 325-5516

 

 

 

 

IL444-4469 (R-5-12) Child Care Rate Certification Form

 

Printed by Authority of the State of Illinois P.O. #12-1386 6,200 copies

Page 2 of 2

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