Form Name (Form Number)

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
Parent/Guardian Name:
Child Care Case Number:
Client:
Date of Notice:
Return your completed Redetermination to:
YWCA Metropolitan Chicago
55 E North Ave.
Glendale Heights, IL 60139
Fax: 630-790-0722
Reason for Child Care:
Caseload Code:
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
need child care for that job. Photocopy this page and complete a separate work information and work schedule section
for each job you have.
Number of jobs currently working
List a phone number where we can reach you during the day:
Job Title
Current Employer/Company Name
Address
City
Work Telephone Number
Ext.
I earn before deductions (complete one)
I get paid (check one)
Zip Code
State
Date you started this job:
$
every day
per hour OR $
every week
every two weeks
twice per month
once per month
other (please explain)
per month OR
Number of hours usually worked at
this job each week
Travel time from the child care provider to work:
$
per year
Number of days usually worked at this
job each week
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
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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,
please complete the following section with your current work information.
Parent/Guardian Name:
New or Corrected Employer/Company Name (Copy and complete additional sheets as necessary)
New or Corrected Address
New or Corrected City
New or Corrected Work Telephone Number
I get paid (check one)
every day
State
Ext.
Updated or Corrected Pay Information (complete one)
every two weeks
twice per month
once per month
other (please explain)
Travel time from the child care provider to work:
per year
per month OR $
Number of hours usually worked at
this job each week
every week
Zip Code
Date you started this job:
per hour OR $
$
New or Corrected Job Title
Number of days usually worked at this
job each week
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
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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 Degree Being Earned (GED/High
TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)
school diploma, trade school certificate, BA
High School or GED
Below Post - Secondary (e.g., ABE or ESL)
degree)
Internship
Occupational/Vocational
2-Year College Degree
4-Year College Degree
Work Experience (TANF only)
What is the highest level of education you have completed (GED/High school
diploma, trade school certificate, BA degree)?
School Name/Training Program Currently Attending
Do you already have a professional license degree, or certificate?
Telephone Number
Address
Term Start Date
City
Travel time from the child care provider to school:
Yes
No
If yes, what type:
Term End Date
State
Zip Code
Do you use public transportation?
SCHOOL SCHEDULE: Please complete the following schedule
MON
TUES
WED
THURS
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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
Occupational/Vocational
Below Post - Secondary (e.g., ABE or ESL)
Internship
2-Year College Degree
4-Year College Degree
Work Experience (TANF only)
Type of Degree Being Earned (GED/High
school diploma, trade school certificate, BA
degree)
Do you already have a professional license, degree, or certificate?
What is the highest level of education you have completed (GED/High school
diploma, trade school certificate, BA degree)?
Yes
No
If yes, what type:
School Name/Training Program Currently Attending
Telephone Number
Address
Term State Date
City
Travel time from the child care provider to school:
Term End Date
State
Zip Code
Do you use public transportation?
NEW OR CORRECTED SCHOOL SCHEDULE: Please complete the following schedule
MON
TUES
WED
THURS
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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
Social Security Number (Optional)
Is the other parent or stepparent working?
M.I.
Last Name
Date of Birth (include month/day/year)
Yes
Is the other parent or stepparent attending school or a training program?
Telephone Number
No
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
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.
Number of jobs they are currently working
Job Title
First Employer/Company Name
Address
City
Work Telephone Number
Ext.
Date they started this job:
$
They earn (complete one):
How often are they paid (check one)
Zip Code
State
per hour OR $
every day
per month OR
every week
every two weeks
twice per month
once per month
other (please explain)
$
per year)
Number of hours usually worked Number of days usually worked
at this job each week
at this job each week
Do you use public transportation?
Travel time from the child care provider to work:
OTHER PARENT WORK SCHEDULE: If their schedule varies, provide an example of the schedule.
MON
TUES
WED
THURS
FRI
Yes
SAT
No
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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
New or Corrected Work Telephone
Ext.
State
Zip Code
Date they started this job:
Updated or Corrected Pay Information (complete one)
$
per hour OR $
They get paid (check one):
per month OR $
every day
every week
every two weeks
twice per month
once per month
other (please explain)
Travel time from the child care provider to work:
IL444-3455E (R-6-11)
per year
Number of hours usually worked Number of days usually worked
at this job each week
at this job each week
Do they use public transportation?
Yes
No
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
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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
Occupational/Vocational
Below Post - Secondary (e.g., ABE or ESL)
Internship
2-Year College Degree
4-Year College Degree
Work Experience (TANF only)
What is the highest level of education they have completed (GED/High school
diploma, trade school certificate, BA degree)?
School Name/Training Program Currently Attending
Type of Degree Being Earned (GED/High
school diploma, trade school certificate, BA
degree)
Do they already have a professional license, degree, or certificate?
Telephone Number
Address
Yes
No
If yes, what type:
Term End Date
Term Start Date
City
State
Zip Code
Do they use public transportation?
Travel time from the child care provider to school:
Yes
No
OTHER PARENT SCHOOL SCHEDULE: Please complete the following schedule
MON
TUES
WED
THURS
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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)
High School or GED
Occupational/Vocational
Below Post - Secondary (e.g., ABE or ESL)
Internship
2-Year College Degree
4-Year College Degree
Work Experience (TANF only)
What is the highest level of education they have completed (GED/High school
diploma, trade school certificate, BA degree)?
Type of Degree Being Earned (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:
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
Address
Term Start Date
City
Travel time from the child care provider to school.
Term End Date
State
Zip Code
Yes
Do they use public transportation?
No
SCHOOL SCHEDULE: Please complete the following schedule
MON
TUES
WED
THURS
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
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.
If any information is no longer correct, please cross out and write in
correct information.
My family size:
I need child care assistance for the following children:
FIRST NAME
LAST NAME
DATE OF
BIRTH
M/F
ETHNIC U.S. CITIZEN
ORIGIN*
YES/NO**
SOCIAL SECURITY
NUMBER (Optional)
WARD OF
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
IL444-3455E (R-6-11)
LAST NAME
DATE OF
BIRTH
RELATIONSHIP
TO APPLICANT
SOCIAL SECURITY
NUMBER (Optional)
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
Relationship to Client:
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
IL444-3455E (R-6-11)
FRI
SAT
SUN
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
Age
Relationship to Client:
THU
AM
PM
Age
Relationship to Client:
WED
AM
PM
Age
Relationship to Client:
TUE
FROM
Age
Relationship to Client:
Child's Name
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Yes
Year Round
No
What hours is the child in school?
If yes, please explain:
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
Relationship to Client:
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
IL444-3455E (R-6-11)
FRI
SAT
SUN
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
Age
Relationship to Client:
THU
AM
PM
Age
Relationship to Client:
WED
AM
PM
Age
Relationship to Client:
TUE
FROM
Age
Relationship to Client:
Child's Name
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Yes
Year Round
No
What hours is the child in school?
If yes, please explain:
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
Relationship to Client:
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
Child's Name
Does the child attend school?
Does the child care schedule vary?
IL444-3455E (R-6-11)
FRI
SAT
SUN
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Year Round
Yes
No
MON
Age
Relationship to Client:
THU
AM
PM
Age
Relationship to Client:
WED
AM
PM
Age
Relationship to Client:
TUE
FROM
Age
Relationship to Client:
Child's Name
MON
What hours is the child in school?
If yes, please explain:
TUE
WED
THU
FRI
SAT
SUN
FROM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
TO
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Yes
No
Yes
Year Round
No
What hours is the child in school?
If yes, please explain:
Page # of ##
State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE REDETERMINATION
Parent/Guardian Name:
SECTION 5 - MONTHLY INCOME INFORMATION
Enter the average MONTHLY income in each box for yourself and each member you have counted in your family size.
Information from various agencies' databases and web sites will be taken into consideration when determining eligibility. If the
Type of Monthly Income does not apply, write N/A.
Applicant (YOU)
Type of Monthly Income
Other Family Members
1. Employment Income for both parents and all family members age 19 and older
(including tips from pay stubs before deductions). Attach copies of 2 most recent
and consecutive pay stubs for each person. If you (or a family member) are self employed,
complete #2.
$
$
$
$
$
$
3. Child Support Received for all family members
$
$
4. TANF Cash Assistance for all family members
5. Other Federal Cash Income: for example, Social Security payments for
$
$
$
$
$
$
SUBTOTAL (add lines 1 - 6)
$
$
SUBTRACT Child Support Paid by you or another family member
-$
-$
TOTAL MONTHLY INCOME
$
$
2. Self Employment Income for you and family member age 19 and older. Attach
verification such as, most recent Federal tax return (IRS 1040 and all attachments),
or a copy of quarterly estimated taxes, or a listing of all business income expenses for
the last 30 days. This can be reported on your own form or 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. Receipts, invoices or other documentation must be attached.
ALL family members and railroad benefits.
6. Other Monthly Income for all family members; for example - unemployment compensation,
ongoing monthly adoption assistance payments from DCFS, permanent disability payments (SSI),
alimony, interest income, royalties, pension, annuities, veteran's pension, survivor's benefits, and living
expenses portion of educational grants.
If you receive any Housing Cash Assistance, including vouchers with a specific cash value, please
report the amount here. This is required for Federal reporting only, and it DOES NOT COUNT IN
TOTAL FAMILY INCOME.
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:
SECTION 6 - PARENT/GUARDIAN CERTIFICATION
After reading each of the following statements, I certify that:
* I understand that I am responsible for paying a share of my child care costs (parent co-payment) to my
child care provider and that failure to do so may result in the loss of my child care provider.
* I understand that my eligibility will be redetermined every six (6) months or as needed.
* The child(ren) is/are current on all immunizations and verification is on file with the child care provider.
* A review of each facility/home has been completed and I agree that it is a safe environment.
* I have given written notification to each child care provider if I want anyone other than myself to pick up
the child(ren).
* I am responsible for the selection of the child care provider(s) for my child(ren).
* I will report any change in child care arrangements, employment or family size, within 10 days. Failure to
report changes in a timely manner may result in an overpayment which I will have to pay back and/or loss
of child care benefits.
* I understand that I must be working or attending an IDHS approved education, training, or other work
related activity in order to be eligible to receive child care benefits.
* I understand the information provided will be checked using State and other databases, and if
inconsistencies are discovered, the processing of my Redetermination may be delayed or denied.
* I understand that deliberately providing an incorrect/fictitious Social Security number or withholding the
Social Security number information in order to defraud the State of Illinois will cause me to be
prosecuted to the fullest extent of the law.
* The information provided will be disclosed only for administrative purposes and that I may be required
to verify the information that I have provided.
* I understand that I have the right to appeal and to have a fair hearing or grievance.
* I declare under penalty of perjury that I have read all statements on this form and the information I give is
true, correct, and complete to the best of my knowledge. I understand that giving false information or
failing to provide correct information can also result in an overpayment which I will have to pay back and
could result in my prosecution for fraud.
My signature is my consent and authorization for information to be released to the Illinois Department of Human Services or
its agents that may establish my eligibility, or my continued eligibility for the child care.
Parent/Guardian's
Signature:
Date:
Other Parent/Guardian Signature:
Date:
YWCA Metropolitan Chicago
55 E North Ave.
Glendale Heights, IL 60139
Fax: 630-790-0722
IL444-3455E (R-6-11)
Page # of ##