By signing below, you swear or affirm, under penalty of perjury, the answers on this application are true and correct to the best of your knowledge.
Persons: list all persons living with you, including yourself; for additional persons, please attach a separate sheet.
Pay stubs: attach copies of the last four pay stubs if paid weekly, last two pay stubs if paid every other week or twice a month, and the last pay stub if paid monthly.
Self employed: if self employed, attach your income and expense statement.
More than one job: if a person works more than one job list all the employers.
| Question | Answer |
|---|---|
| Form Name | IL 444-4765 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 123 |
| Avg. time to fill out | 21 min |
| Edition | R-05-16 |
| Issuing agency | Illinois Department of Human Services |
| Other names | IL 444-4765, IL444-4765, IL 4444765, Illinois Redetermination Application |
| Official source | IL 444-4765 (Rev R-05-16), Illinois Department of Human Services |
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