Kids Redetermination PDF Details

The Department of Children and Families (DCF) has released a new form to help streamline the redetermination process for children’s Medicaid eligibility. The Kids Redetermination Form is designed to make it easier for families to provide information and documentation needed to determine their child’s eligibility. This new form was created in response to feedback from parents and advocates, who expressed the need for a simpler and more user-friendly application. The Kids Redetermination Form can be accessed on the DCF website at www.mass.gov/dcf. Families are encouraged to use this new form when they need to reapply for Medicaid coverage for their children.

You may find information regarding the type of form you need to prepare in the table. It will tell you the span of time you will need to complete kids redetermination, what fields you need to fill in, etc.

QuestionAnswer
Form NameKids Redetermination
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesaction for kids redetermination, action for children application, redetermination form for child care illinois, illinois action for children redetermination

Form Preview Example

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

Client:

Parent/Guardian Name:

Date of Notice:

KEEP FOR YOUR RECORDS

The State of Illinois helps income eligible families pay for their child care services while they work or go to school, training and other work-related activities. To apply please read the following pages carefully and then submit your completed Redetermination to your local Child Care Resource and Referral (CCR&R) or child care center/home if they have a contract with IDHS to provide child care assistance. If you have any questions about your eligibility or if you need help completing this form, call your local CCR&R. To find your local CCR&R go to http://www.inccrra.org/find-your-local-ccrr-other or call 1-877-202-4453 (toll-free).

Please be sure that all of the information is complete before sending in your Redetermination:

*The Redetermination is filled out clearly in blue or black ink.

*All questions on the Redetermination are complete. If the section or question does not apply, write "n/a in the box to show that the question was not missed.

*This information is for your current job/education activity. You will inform the CCR&R or Site provider if any information changes in the future.

*The parent/guardian's name is listed at the top of each page of the Redetermination.

*Both you and the other parent/adult have signed the Redetermination (page 12).

*All social security numbers are listed clearly or "n/a" is listed in the box. Social security numbers are not required for parents or children but they are used to gather information to help determine your eligibility for child care assistance. All information is confidential and will not be shared with anyone else.

*All Family Information is complete in Section 3 (page 7) including information about your children's immigration status. Children can get assistance regardless of their immigration status, but IDHS is required to ask for this information. This information will not be shared with anyone. Your child's alien registration number must be listed if they have one.

*All persons living in your household are listed in Section 3 (page 7).

*If working, at least one of the following is attached to verify your employment and the employment of everyone listed in your family size that is 19 years of age or older:

**Copies of your last (2) paycheck stubs, or if you have not been working long enough to get two paychecks:

--A letter from your employer or an employment verification form listing the following:

The date you started working.

The amount of money you are paid.

Your typical work schedule, including the total number of hours you work per week.

Your employer's address and phone number.

Your employer's signature, or

**Verification of your self-employment. This can include:

--A copy of your most recent Federal income tax return (IRS 1040) and all schedules and attachments.

--A copy of your quarterly estimated taxes.

--A listing of all business income and expenses for the last 30 days. This can be reported on your own form or on a Self-Employment form which can be downloaded at http://www.dhs.state.il.us/OneNetLibrary/27897 /documents/Forms/IL444-2790.pdf or requested from your local CCR&R. When reporting income and expenses, receipts, invoices, or other documentation must be attached to verify all information.

*If in school, ALL of the following are attached:

**Copies of your official school schedule.

**Copies of your most recent report card showing your cumulative grade point average (GPA).

*You have made a copy of your Redetermination for your records. You understand if you send original check stubs or other documents that they will not be returned.

*All jobs and income information for BOTH parents have been reported on pages 3 through 6 and documentation is attached.

*You understand that if any questions are left blank or if any attachments are missing, your redetermination form will be returned to you as incomplete. This may cause a delay in approval for Child Care Assistance Program payments.

*You also understand that all of the information you submit will be verified using State and/or local databases and the internet. If any inconsistencies are discovered, your redetermination may be delayed or your participation in the Child Care Assistance Program may be cancelled.

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

Child Care Case Number:

Parent/Guardian Name:

Client:

 

Date of Notice:

 

 

Return your completed Redetermination to:

Caseload Code:

Reason for Child Care:

Provider(s):

 

Your eligibility for CHILD CARE needs to be Redetermined at this time. Please complete and return this form to us at the address

listed above. If we do not receive this information within 10 business days, your child care will be CANCELED. If you are having problems filling out this form, please contact us.

IF YOU'RE EMPLOYED, ATTACH COPIES OF YOUR 2 MOST RECENT PAYSTUBS.

IF YOU'RE ATTENDING A TANF REQUIRED ACTIVITY (such as education or training), ATTACH A COPY OF YOUR CURRENT RESPONSIBILITY AND SERVICE PLAN (RSP).

IF YOU'RE ATTENDING SCHOOL BUT NOT ON TANF, ATTACH A COPY OF YOUR SCHOOL SCHEDULE AND MOST RECENT REPORT CARD. IF YOU'RE A TEEN PARENT ATTENDING HIGH SCHOOL/GED, ONLY A COPY OF YOUR SCHOOL SCHEDULE IS NEEDED.

PLEASE PRINT CLEARLY IN BLUE OR BLACK INK.

PLEASE READ THE ATTACHED INSTRUCTIONS BEFORE COMPLETING THIS FORM (P. 1).

SECTION 1 - PARENT/GUARDIAN INFORMATION

WORK INFORMATION - If you are working more than one job, you MUST tell us about all your jobs even if don't

 

Number of jobs currently working

 

 

need child care for that job. Photocopy this page and complete a separate work information and work schedule section

 

 

 

for each job you have.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List a phone number where we can reach you during the day:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Employer/Company Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Job Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Telephone Number

 

 

 

 

Ext.

 

 

 

 

 

Date you started this job:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I earn before deductions (complete one)

$

 

 

 

 

 

 

per hour OR

$

 

 

 

 

 

 

per month OR $

 

 

 

 

per year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I get paid (check one)

 

 

 

every day

 

 

 

 

every week

 

 

 

Number of hours usually worked at

 

Number of days usually worked at this

 

 

 

 

 

 

 

 

 

every two weeks

 

 

 

twice per month

 

 

 

this job each week

 

 

 

 

 

 

 

job each week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

 

 

 

 

 

AM

 

 

 

AM

 

 

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

 

PM

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

 

 

 

 

 

AM

 

 

 

AM

 

 

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

 

PM

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If your schedule varies, please explain how (you may send additional schedules to show how).

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

If any of the information on the previous page is incorrect or has changed, Parent/Guardian Name: please complete the following section with your current work information.

New or Corrected Employer/Company Name (Copy and complete additional sheets as necessary)

New or Corrected Job Title

 

 

New or Corrected Address

 

 

 

 

New or Corrected City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New or Corrected Work Telephone Number

 

 

 

 

 

Ext.

Date you started this job:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Updated or Corrected Pay Information (complete one)

$

 

 

per hour OR $

 

 

per month OR $

 

 

per year

 

 

 

 

 

 

 

I get paid (check one)

 

every day

 

every week

 

Number of hours usually worked at

Number of days usually worked at this

 

 

 

 

every two weeks

 

twice per month

 

 

 

this job each week

 

 

job each week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

once per month

 

other (please explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Travel time from the child care provider to work:

 

 

 

 

Do you use public transportation?

 

 

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

 

 

 

MON

 

 

 

 

TUES

 

WED

 

 

 

THURS

 

FRI

 

SAT

 

 

 

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

AM

 

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

AM

 

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If your schedule

varies, please

explain how (you

may send additional schedules

to verify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this a new job since your last redetermination?

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, your previous employer's name:

 

 

 

 

 

 

 

 

 

 

 

 

Date previous job ended:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION

 

 

 

 

 

 

 

 

 

 

Are you currently attending school, training or a TANF-Required Activity?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No (Go to Section 2 - Other Parent/Stepparent Information P. 4)

 

 

 

Yes (Verify/Complete the information below.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)

Type of Degree Being Earned (GED/High

 

 

High School or GED

 

 

 

 

Below Post - Secondary (e.g., ABE or ESL)

school diploma, trade school certificate, BA

 

 

 

 

 

 

 

 

 

 

 

 

degree)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupational/Vocational

 

 

 

2-Year College Degree

 

 

 

Internship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4-Year College Degree

 

 

 

Work Experience (TANF only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What is the highest level of education you have completed (GED/High school

 

Do you already have a professional license degree, or certificate? Yes

No

diploma, trade school certificate, BA degree)?

 

 

 

 

If yes, what type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Name/Training Program Currently Attending

Telephone Number

 

 

 

 

 

 

 

Term Start Date

 

 

 

Term End Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Travel time from the child care provider to school:

 

 

 

 

 

 

 

 

 

 

 

Do you use public transportation?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHOOL SCHEDULE: Please complete the following schedule

 

 

 

 

 

 

 

 

 

 

 

 

 

MON

 

 

 

 

TUES

 

WED

 

 

 

THURS

 

FRI

 

SAT

 

 

 

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

AM

 

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

AM

 

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

PM

 

 

 

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PM

 

 

 

 

 

PM

 

 

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

If any of the information on the previous page is incorrect or has changed, please complete the following section with your current school/training information.

Parent/Guardian Name:

NEW OR CORRECTED SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION

TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)

 

High School or GED

 

Below Post - Secondary (e.g., ABE or ESL)

 

 

 

Occupational/Vocational

 

2-Year College Degree

 

Internship

 

 

 

 

 

 

 

 

4-Year College Degree

 

Work Experience (TANF only)

 

 

 

 

 

 

 

Type of Degree Being Earned (GED/High school diploma, trade school certificate, BA degree)

What is the highest level of education you have completed (GED/High school diploma, trade school certificate, BA degree)?

Do you already have a professional license, degree, or certificate?

Yes

No

 

If yes, what type:

School Name/Training Program Currently Attending

Telephone Number

Term State Date

Term End Date

Address

City

State

Zip Code

Travel time from the child care provider to school:Do you use public transportation?

NEW OR CORRECTED SCHOOL SCHEDULE: Please complete the following schedule

 

 

 

MON

TUES

 

WED

THURS

FRI

 

SAT

 

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

AM

 

 

AM

 

 

 

AM

 

 

 

 

AM

 

 

AM

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

PM

 

 

 

PM

 

 

 

 

PM

 

 

PM

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

AM

 

 

AM

 

 

 

AM

 

 

 

 

AM

 

 

AM

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

PM

 

 

 

PM

 

 

 

 

PM

 

 

PM

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2 - OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION

 

 

 

 

 

 

 

Is the other parent or stepparent of any of your children, step children or wards living in your home?

 

 

 

 

 

 

 

 

 

No (Go to Section 3 - Family Information P. 7)

 

 

 

 

 

 

 

Yes (Complete the information below.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please note: Information from various agencies' database and internet web sites will be taken into consideration.

If the information does not match it may delay your eligibility.

If the other parent or stepparent could be listed on your case for other benefits (TANF, SNAP/Food Stamps, Medical, Child Support Enforcement, Unemployment) but is no longer living with you, you may need to supply additional information to prove he/she is living somewhere else. If you cannot provide this documentation, please contact your local CCR&R or Site Administered child care provider.

OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION

Other Parent/Guardian/Stepparent First Name

 

M.I.

Last Name

 

 

 

 

 

 

 

 

Social Security Number (Optional)

Date of Birth (include month/day/year)

 

Telephone Number

 

 

 

 

 

 

Is the other parent or stepparent working?

 

Yes

No

 

 

Is the other parent or stepparent attending school or a training program?

Yes

No

If the other parent or stepparent is not working or in a school/training program, please explain why he/she cannot care for the children.

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

 

Parent/Guardian Name:

 

 

 

 

WORK INFORMATION - If the other parent/stepparent is working more than one job, you MUST tell us about all their

Number of jobs they are currently working

jobs even if you don't need child care for that job. Photocopy this page and complete a separate work information and

work schedule section for each job they have.

 

First Employer/Company Name

Job Title

Address

City

State

Zip Code

Work Telephone Number

Ext.

Date they started this job:

They earn (complete one):

$

 

 

 

per hour OR $

 

 

per month OR $

 

 

per year)

 

 

 

 

 

 

 

 

 

 

 

 

 

How often are they paid (check one)

 

every day

 

every week

Number of hours usually worked

Number of days usually worked

 

 

 

 

every two weeks

 

 

 

twice per month

 

 

at this job each week

at this job each week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

once per month

 

 

 

other (please explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Travel time from the child care provider to work:

 

 

 

 

 

Do you use public transportation?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PARENT WORK SCHEDULE: If their schedule varies, provide an example of the schedule.

 

MON

TUES

WED

THURS

FRI

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If other parent/stepparents schedule varies, please explain how (you may send additional schedules to show how.)

If any information is incorrect or has changed, please complete the following

section with the current work information for the other Parent/Guardian.

NEW OR CORRECTED OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION

Other Parent's New or Corrected Employer/Company Name (Please copy and complete additional sheets as necessary)

New or Corrected Job Title

 

 

New or Corrected Address

 

 

 

 

 

 

 

 

New or Corrected City

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New or Corrected Work Telephone

 

 

 

 

 

 

 

 

Ext.

Date they started this job:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Updated or Corrected Pay Information (complete one)

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

per hour OR $

 

per month OR $

 

 

per year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

They get paid (check one):

 

every day

 

every week

Number of hours usually worked

Number of days usually worked

 

 

 

 

 

 

every two weeks

 

twice per month

 

 

at this job each week

at this job each week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

once per month

 

other (please explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Travel time from the child care provider to work:

 

 

 

 

 

Do they use public transportation?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

Parent/Guardian Name:

OTHER PARENT WORK SCHEDULE: If the schedule varies, provide an example of the schedule.

 

MON

TUES

WED

THURS

FRI

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

AM

 

 

 

 

 

 

 

 

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If their schedule varies, please explain how (you may send additional schedules to show how.)

OTHER PARENT SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION

Is the other parent/guardian/stepparent currently attending school, training or a TANF-Required Activity?

NO (Go to Section 3 - Family Information P. 7)

YES (Complete the information below)

TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)

 

High School or GED

 

Below Post - Secondary (e.g., ABE or ESL)

 

 

 

Occupational/Vocational

 

2-Year College Degree

 

Internship

 

 

 

 

 

 

 

 

4-Year College Degree

 

Work Experience (TANF only)

 

 

 

 

 

 

 

Type of Degree Being Earned (GED/High school diploma, trade school certificate, BA degree)

What is the highest level of education they have completed (GED/High school diploma, trade school certificate, BA degree)?

Do they already have a professional license, degree, or certificate?

 

Yes

 

No

 

 

If yes, what type:

 

 

 

 

School Name/Training Program Currently Attending

Telephone Number

Term Start Date

Term End Date

Address

City

State

Zip Code

Travel time from the child care provider to school:

 

 

 

 

 

 

 

Do they use public transportation?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PARENT SCHOOL SCHEDULE: Please complete the following schedule

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MON

 

 

TUES

 

WED

 

 

THURS

 

FRI

 

SAT

 

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

AM

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

AM

 

 

 

AM

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

PM

 

 

 

PM

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

AM

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

AM

 

 

 

AM

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

PM

 

 

 

PM

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEW OR CORRECTED OTHER PARENT SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION

 

 

 

 

 

 

 

 

 

 

If any of the information above is incorrect or has changed, please complete the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

following section with your current school/training information.

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)

Type of Degree Being Earned (GED/High

 

 

High School or GED

 

 

Below Post - Secondary (e.g., ABE or ESL)

school diploma, trade school certificate, BA

 

 

 

 

 

 

 

 

degree)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupational/Vocational

 

 

2-Year College Degree

 

 

Internship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4-Year College Degree

 

 

Work Experience (TANF only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What is the highest level of education they have completed (GED/High school

Do they already have a professional license, degree, or certificate?

Yes No

diploma, trade school certificate, BA degree)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, what type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

NEW OR CORRECTED OTHER PARENT SCHOOL/TRAINING/

 

 

 

 

Parent/Guardian Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TANF-REQUIRED ACTIVITY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Name/Training Program Currently Attending

 

 

 

 

 

Telephone Number

 

 

 

 

 

Term Start Date

 

 

Term End Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Travel time from the child care provider to school.

 

 

 

 

 

 

 

Do they use public transportation?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHOOL SCHEDULE: Please complete the following schedule

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MON

 

TUES

 

 

 

 

WED

 

 

 

 

THURS

 

FRI

 

 

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

AM

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

PM

 

 

 

 

 

 

PM

 

 

 

 

PM

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

 

 

 

AM

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

 

AM

 

 

 

 

AM

 

 

 

 

AM

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

PM

 

 

 

 

 

 

PM

 

 

 

 

PM

 

 

 

 

PM

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 3 - FAMILY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

Family size includes these people LIVING IN YOUR HOME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*

You,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*

Your biological or adopted children under age 21.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*

The biological, step or adoptive parent of any of your children must be included.

 

 

 

 

 

 

 

 

 

 

 

 

 

*

Any other person related to you by blood or law for whom you provide more than 50% of their support (if you choose to

 

include them and can verify their income) - for example an elderly parent or disabled person.

 

 

 

 

 

 

 

 

 

 

My family size:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If any information is no longer correct, please cross out and write in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

correct information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I need child care assistance for the following children:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

LAST NAME

 

 

DATE OF

 

M/F

ETHNIC

 

 

U.S. CITIZEN

SOCIAL SECURITY

WARD OF

 

 

 

BIRTH

 

ORIGIN*

 

YES/NO**

NUMBER (Optional)

THE STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Yes

 

 

No

*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 Redetermination) counted in your family size:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

LAST NAME

 

 

 

DATE OF

 

RELATIONSHIP

 

SOCIAL SECURITY

 

 

 

 

 

 

BIRTH

 

 

TO APPLICANT

 

NUMBER (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

SECTION 4 - CHILD CARE ARRANGEMENT

Parent/Guardian Name:

 

 

If any of the information below has changed, please cross out the wrong information and NEATLY write in the correct

information. Use an extra piece of paper or the bottom of this page, if necessary.

LIST THE CHILDREN CARED FOR BY EACH PROVIDER. If your children go to school, preschool, or Headstart during the day, list only the hours that they are with the child care provider. (This is not a Provider Change Form.)

1) Provider Name:

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

 

 

 

 

 

 

 

 

Parent/Guardian Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2) Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-3455E (R-6-11)

Page # of ##

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE REDETERMINATION

 

 

 

 

 

 

 

 

Parent/Guardian Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3) Provider Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child's Name

 

Age

 

 

MON

 

TUE

 

WED

 

THU

FRI

 

SAT

SUN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

Relationship to Client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO

AM

 

AM

 

AM

 

AM

AM

 

AM

AM

 

 

 

 

 

 

 

 

 

 

PM

 

PM

 

PM

 

PM

PM

 

PM

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child attend school?

 

 

Yes

No

Year Round

What hours is the child in school?

 

 

 

Does the child care schedule vary?

 

 

 

Yes

No

If yes, please explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-3455E (R-6-11)

Page # of ##

Watch Kids Redetermination Video Instruction

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