Form IL444-3455E "Child Care Redetermination" - Illinois

What Is Form IL444-3455E?

This is a legal form that was released by the Illinois Department of Human Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2011;
  • The latest edition provided by the Illinois Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form IL444-3455E by clicking the link below or browse more documents and templates provided by the Illinois Department of Human Services.

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Download Form IL444-3455E "Child Care Redetermination" - Illinois

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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
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:
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
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:
Job Title
Current Employer/Company Name
Zip Code
Address
City
State
Work Telephone Number
Ext.
Date you started this job:
$
$
$
per hour OR
per month OR
I earn before deductions (complete one)
per year
I get paid (check one)
Number of hours usually worked at
Number of days usually worked at this
every day
every week
this job each week
job each week
every two weeks
twice per month
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
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
TO
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
Parent/Guardian Name:
If any of the information on the previous page is incorrect or has changed,
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 year
per hour OR $
per month OR $
$
I get paid (check one)
Number of hours usually worked at
Number of days usually worked at this
every day
every week
this job each week
job each week
every two weeks
twice per month
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
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
TO
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 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)
Do you already have a professional license degree, or certificate?
What is the highest level of education you have completed (GED/High school
No
Yes
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
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
TO
PM
PM
PM
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,
Parent/Guardian Name:
please complete the following section with your current school/training information.
NEW OR CORRECTED SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION
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)
Do you already have a professional license, degree, or certificate?
What is the highest level of education you have completed (GED/High school
Yes
No
diploma, trade school certificate, BA degree)?
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
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
TO
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
Last Name
Other Parent/Guardian/Stepparent First Name
M.I.
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 ot
her 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.
Job Title
First Employer/Company Name
Zip Code
Address
City
State
Work Telephone Number
Ext.
Date they started this job:
$
$
$
per hour OR
per month OR
They earn (complete one):
per year)
How often are they paid (check one)
Number of hours usually worked
Number of days usually worked
every day
every week
at this job each week
at this job each week
every two weeks
twice per month
once per month
other (please explain)
Do you use public transportation?
Travel time from the child care provider to work:
Yes
No
OTHER PARENT WORK SCHEDULE: If their schedule varies, provide an example of the schedule.
MON
TUES
WED
THURS
FRI
SAT
SUN
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
TO
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 year
per hour OR $
per month OR $
$
They get paid (check one):
Number of hours usually worked
Number of days usually worked
every day
every week
at this job each week
at this job each week
every two weeks
twice per month
once per month
other (please explain)
Do they use public transportation?
Travel time from the child care provider to work:
Yes
No
IL444-3455E (R-6-11)
Page # of ##