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.
Question | Answer |
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Form Name | Kids Redetermination |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | action for kids redetermination, action for children application, redetermination form for child care illinois, illinois action for children redetermination |
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
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
--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
*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.
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: |
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Date of Notice: |
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Return your completed Redetermination to: |
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Caseload Code: |
Reason for Child Care: |
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Provider(s): |
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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 |
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Number of jobs currently working |
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need child care for that job. Photocopy this page and complete a separate work information and work schedule section |
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for each job you have. |
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List a phone number where we can reach you during the day: |
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Current Employer/Company Name |
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Work Telephone Number |
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Date you started this job: |
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I earn before deductions (complete one) |
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per hour OR |
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per month OR $ |
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per year |
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I get paid (check one) |
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every day |
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every week |
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Number of hours usually worked at |
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Number of days usually worked at this |
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every two weeks |
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twice per month |
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this job each week |
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job each week |
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once per month |
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other (please explain) |
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Travel time from the child care provider to work: |
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Do you use public transportation? |
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WORK SCHEDULE: If your schedule varies, provide an example of your schedule. |
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If your schedule varies, please explain how (you may send additional schedules to show how).
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 |
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New or Corrected Address |
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New or Corrected City |
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New or Corrected Work Telephone Number |
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Ext. |
Date you started this job: |
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Updated or Corrected Pay Information (complete one) |
$ |
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per hour OR $ |
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per month OR $ |
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per year |
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I get paid (check one) |
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every day |
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every week |
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Number of hours usually worked at |
Number of days usually worked at this |
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every two weeks |
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twice per month |
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this job each week |
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job each week |
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once per month |
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other (please explain) |
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Travel time from the child care provider to work: |
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Do you use public transportation? |
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NEW OR CORRECTED WORK SCHEDULE: If your schedule varies, provide an example of your schedule.
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If your schedule |
varies, please |
explain how (you |
may send additional schedules |
to verify): |
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Is this a new job since your last redetermination? |
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If YES, your previous employer's name: |
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Date previous job ended: |
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Are you currently attending school, training or a |
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No (Go to Section 2 - Other Parent/Stepparent Information P. 4) |
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Yes (Verify/Complete the information below.) |
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TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one) |
Type of Degree Being Earned (GED/High |
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High School or GED |
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school diploma, trade school certificate, BA |
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degree) |
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Work Experience (TANF only) |
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What is the highest level of education you have completed (GED/High school |
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Do you already have a professional license degree, or certificate? Yes |
No |
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diploma, trade school certificate, BA degree)? |
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If yes, what type: |
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School Name/Training Program Currently Attending |
Telephone Number |
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Term Start Date |
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Travel time from the child care provider to school: |
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Do you use public transportation? |
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SCHOOL SCHEDULE: Please complete the following schedule |
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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
TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)
|
High School or GED |
|
Below Post - Secondary (e.g., ABE or ESL) |
||
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Occupational/Vocational |
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Internship |
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Work Experience (TANF only) |
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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
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MON |
TUES |
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WED |
THURS |
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SUN |
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SECTION 2 - OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION |
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Is the other parent or stepparent of any of your children, step children or wards living in your home? |
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No (Go to Section 3 - Family Information P. 7) |
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Yes (Complete the information below.) |
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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 |
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M.I. |
Last Name |
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Social Security Number (Optional) |
Date of Birth (include month/day/year) |
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Telephone Number |
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Is the other parent or stepparent working? |
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Yes |
No |
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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.
Page # of ## |
State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE REDETERMINATION
|
Parent/Guardian Name: |
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|
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 |
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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. |
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First Employer/Company Name
Job Title
Address
City
State
Zip Code
Work Telephone Number |
Ext. |
Date they started this job:
They earn (complete one): |
$ |
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per hour OR $ |
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per month OR $ |
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per year) |
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How often are they paid (check one) |
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every day |
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every week |
Number of hours usually worked |
Number of days usually worked |
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every two weeks |
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twice per month |
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at this job each week |
at this job each week |
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once per month |
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other (please explain) |
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Travel time from the child care provider to work: |
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Do you use public transportation? |
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Yes |
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No |
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OTHER PARENT WORK SCHEDULE: If their schedule varies, provide an example of the schedule.
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MON |
TUES |
WED |
THURS |
FRI |
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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
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New or Corrected Work Telephone |
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Ext. |
Date they started this job: |
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Updated or Corrected Pay Information (complete one) |
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per hour OR $ |
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per month OR $ |
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per year |
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They get paid (check one): |
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every day |
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every week |
Number of hours usually worked |
Number of days usually worked |
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every two weeks |
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twice per month |
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at this job each week |
at this job each week |
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once per month |
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other (please explain) |
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Travel time from the child care provider to work: |
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Do they use public transportation? |
Yes |
No |
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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.
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MON |
TUES |
WED |
THURS |
FRI |
SAT |
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If their schedule varies, please explain how (you may send additional schedules to show how.)
OTHER PARENT
Is the other parent/guardian/stepparent currently attending school, training or a
NO (Go to Section 3 - Family Information P. 7) |
YES (Complete the information below) |
TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)
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High School or GED |
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Below Post - Secondary (e.g., ABE or ESL) |
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Occupational/Vocational |
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Internship |
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Work Experience (TANF only) |
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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? |
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Yes |
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No |
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If yes, what type: |
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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: |
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Do they use public transportation? |
Yes |
No |
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OTHER PARENT SCHOOL SCHEDULE: Please complete the following schedule |
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NEW OR CORRECTED OTHER PARENT |
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If any of the information above is incorrect or has changed, please complete the |
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following section with your current school/training information. |
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TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one) |
Type of Degree Being Earned (GED/High |
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High School or GED |
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Below Post - Secondary (e.g., ABE or ESL) |
school diploma, trade school certificate, BA |
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degree) |
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Internship |
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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 |
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diploma, trade school certificate, BA degree)? |
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If yes, what type: |
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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/ |
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Parent/Guardian Name: |
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School Name/Training Program Currently Attending |
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Travel time from the child care provider to school. |
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Do they use public transportation? |
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SCHOOL SCHEDULE: Please complete the following schedule |
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SECTION 3 - FAMILY INFORMATION |
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Family size includes these people LIVING IN YOUR HOME: |
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* |
You, |
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* |
Your biological or adopted children under age 21. |
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* |
The biological, step or adoptive parent of any of your children must be included. |
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* |
Any other person related to you by blood or law for whom you provide more than 50% of their support (if you choose to |
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include them and can verify their income) - for example an elderly parent or disabled person. |
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My family size: |
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If any information is no longer correct, please cross out and write in |
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correct information. |
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I need child care assistance for the following children: |
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FIRST NAME |
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LAST NAME |
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DATE OF |
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M/F |
ETHNIC |
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U.S. CITIZEN |
SOCIAL SECURITY |
WARD OF |
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BIRTH |
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ORIGIN* |
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YES/NO** |
NUMBER (Optional) |
THE STATE |
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*For each child's Ethnic Origin, list all numbers below that apply: (Required for Federal Reporting) 1 - White 2 - Black or |
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African American 3 - Hispanic or Latino (Persons declaring Hispanic ethnicity should also list their race, for example, |
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** If any of the children are not citizens, provide alien registration documentation if you have it. |
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List all other family members (not already listed in the Redetermination) counted in your family size: |
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FIRST NAME |
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LAST NAME |
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DATE OF |
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RELATIONSHIP |
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SOCIAL SECURITY |
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BIRTH |
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TO APPLICANT |
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NUMBER (Optional) |
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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: |
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If any of the information below has changed, please cross out the wrong information and NEATLY write in the correct |
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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 |
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Age |
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TUE |
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WED |
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THU |
FRI |
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FROM |
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Relationship to Client: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
Yes |
No |
If yes, please explain: |
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Child's Name |
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FRI |
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FROM |
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Relationship to Client: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
Yes |
No |
If yes, please explain: |
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Child's Name |
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FRI |
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Relationship to Client: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
Yes |
No |
If yes, please explain: |
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Child's Name |
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Age |
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FRI |
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Relationship to Client: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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||||||||
Does the child care schedule vary? |
Yes |
No |
If yes, please explain: |
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Child's Name |
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Age |
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MON |
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TUE |
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WED |
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THU |
FRI |
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SAT |
SUN |
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FROM |
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AM |
AM |
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PM |
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PM |
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PM |
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PM |
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Relationship to Client: |
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TO |
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AM |
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AM |
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AM |
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No |
Year Round |
What hours is the child in school? |
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Yes |
No |
If yes, please explain: |
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Page # of ## |
State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE REDETERMINATION
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Does the child attend school? |
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Year Round |
What hours is the child in school? |
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Does the child attend school? |
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Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Page # of ## |
State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE REDETERMINATION
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Parent/Guardian Name: |
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3) Provider Name: |
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Child's Name |
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FRI |
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Relationship to Client: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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||||||||
Does the child care schedule vary? |
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Yes |
No |
If yes, please explain: |
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Does the child attend school? |
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Yes |
No |
Year Round |
What hours is the child in school? |
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||||||||
Does the child care schedule vary? |
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||||||||||||||
Yes |
No |
If yes, please explain: |
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