Form CFS678-SE "Day Care Services Eligibility - Verification of Self-employment Form" - Illinois

What Is Form CFS678-SE?

This is a legal form that was released by the Illinois Department of Children and Family 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 December 1, 2015;
  • The latest edition provided by the Illinois Department of Children and Family 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 CFS678-SE by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS678-SE "Day Care Services Eligibility - Verification of Self-employment Form" - Illinois

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CFS 678-SE
12/2015
State of Illinois
Department of Children and Family Services
Day Care Services Eligibility - Verification of Self-Employment Form
I hereby release the below information to the Illinois Department of Children and Family Services
(IDCFS) for the purpose of verifying my current employment.
Applicant Name
Applicant Signature
Date
SELF-EMPLOYMENT INFORMATION
Social Security Number / FEIN:
Hours dedicated to business/work-related matters each day:
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Number of hours per day of day care requested in a scheduled work week:
Company/Entity Name/DBA:
Business Address:
Business Phone:
Please Note:
To verify self-employment, please attach a copy of your recently filed Internal Revenue Service (IRS) Schedule SE
(Form 1040), along with one of the following:
a) copy of recent business/office lease/mortgage, office/workspace rent receipt;
b) copy of your business monthly utility bills (phone, electric, etc.)
c) current business bank statement;
d) list of assets; and/or e) copies of (reacted) contracts.
I hereby certify by my signature that the above information is accurate. If the information is found to
be false, DCFS has the right to recoup funds and/or prosecute:
Applicant Signature
Date
DCFS/POS Case worker Information:
DCFS/POS Caseworker’s Name and Phone number
Definitions (from the American Heritage College Dictionary – Third Edition – 1997):
Self-employed
Earning one’s livelihood directly from one’s own trade or business rather than as an employee of another.
Free-lance
A person, especially writer or artist, who sells his or her services to employers without a long-term commitment.
CFS 678-SE
12/2015
State of Illinois
Department of Children and Family Services
Day Care Services Eligibility - Verification of Self-Employment Form
I hereby release the below information to the Illinois Department of Children and Family Services
(IDCFS) for the purpose of verifying my current employment.
Applicant Name
Applicant Signature
Date
SELF-EMPLOYMENT INFORMATION
Social Security Number / FEIN:
Hours dedicated to business/work-related matters each day:
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Number of hours per day of day care requested in a scheduled work week:
Company/Entity Name/DBA:
Business Address:
Business Phone:
Please Note:
To verify self-employment, please attach a copy of your recently filed Internal Revenue Service (IRS) Schedule SE
(Form 1040), along with one of the following:
a) copy of recent business/office lease/mortgage, office/workspace rent receipt;
b) copy of your business monthly utility bills (phone, electric, etc.)
c) current business bank statement;
d) list of assets; and/or e) copies of (reacted) contracts.
I hereby certify by my signature that the above information is accurate. If the information is found to
be false, DCFS has the right to recoup funds and/or prosecute:
Applicant Signature
Date
DCFS/POS Case worker Information:
DCFS/POS Caseworker’s Name and Phone number
Definitions (from the American Heritage College Dictionary – Third Edition – 1997):
Self-employed
Earning one’s livelihood directly from one’s own trade or business rather than as an employee of another.
Free-lance
A person, especially writer or artist, who sells his or her services to employers without a long-term commitment.