Form CFS851 "Foster Child Damage Reimbursement Program Claim Form" - Illinois

What Is Form CFS851?

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 April 1, 2013;
  • 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 CFS851 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form CFS851 "Foster Child Damage Reimbursement Program Claim Form" - Illinois

Download PDF

Fill PDF online

Rate (4.4 / 5) 13 votes
CFS 851
State of Illinois
Rev 4/2013
Illinois Department of Children and Family Services
FOSTER CHILD DAMAGE REIMBURSEMENT PROGRAM CLAIM FORM
PLEASE PRINT OR TYPE
NOTE: All applicable sections of the form must be completed and the form must be signed, dated, and mailed to: Foster Child Damage
th
Reimbursement Program Coordinator, DCFS, 100 W. Randolph, 6
Floor, Chicago, Il 60601. Phone 312-814-7294.
Please refer to the instructions on Page 3. Each numbered item there corresponds with the item of the same number on this form.
Name
Home Phone #
Cell Phone #
Address
City
Zip Code
1.
FOSTER PARENT
e-mail Address
Name
Date of Birth
DCFS ID#
Case Worker Name
Case Worker Agency
2.
FOSTER CHILD &
CASE WORKER
Case Worker Mailing Address
Case Worker Telephone #
Date
Time
AM
PM
3.
INCIDENT DATE
& LOCATION
Address, City & State
Name of Claimant
Claimant Mailing Address
4.
CLAIMANT
Home Address
Home Telephone#
IDENTITY &
Claimant Social Security #
CLAIMANT
INSURANCE
Claimant Insurance Co.
Insurance Policy #
PROVIDER
Insurance Agent Name & Telephone #
Insurance Type:
Personal
Auto
Health
Home
5.
PERSONAL
Name of Each Person Injured
Date of Birth
INJURY
INFORMATION
Injured Person Address
Telephone # of Injured Person
Employer, Parent or Guardian Name and Address
Name of Health Insurance Carrier
Phone #
Address of Health Insurance Carrier
Policy #
Nature and Extent of Personal Injury
Name and Address of Medical Service Provider
Phone #
6.
PROPERTY
Owner of Damaged Property
Property Owner’s Social Security #
DAMAGE
Phone #
INFORMATION
Owner Address
City
Zip Code
List all items that were damaged or destroyed
Original Vendor, purchase date, & purchase price
Vendor phone #
Original Vendor, purchase date, & purchase price
Vendor phone #
Original Vendor, purchase date & purchase price
Vendor phone #
Owner’s estimate of total cost to repair/replace damaged items
1
CFS 851
State of Illinois
Rev 4/2013
Illinois Department of Children and Family Services
FOSTER CHILD DAMAGE REIMBURSEMENT PROGRAM CLAIM FORM
PLEASE PRINT OR TYPE
NOTE: All applicable sections of the form must be completed and the form must be signed, dated, and mailed to: Foster Child Damage
th
Reimbursement Program Coordinator, DCFS, 100 W. Randolph, 6
Floor, Chicago, Il 60601. Phone 312-814-7294.
Please refer to the instructions on Page 3. Each numbered item there corresponds with the item of the same number on this form.
Name
Home Phone #
Cell Phone #
Address
City
Zip Code
1.
FOSTER PARENT
e-mail Address
Name
Date of Birth
DCFS ID#
Case Worker Name
Case Worker Agency
2.
FOSTER CHILD &
CASE WORKER
Case Worker Mailing Address
Case Worker Telephone #
Date
Time
AM
PM
3.
INCIDENT DATE
& LOCATION
Address, City & State
Name of Claimant
Claimant Mailing Address
4.
CLAIMANT
Home Address
Home Telephone#
IDENTITY &
Claimant Social Security #
CLAIMANT
INSURANCE
Claimant Insurance Co.
Insurance Policy #
PROVIDER
Insurance Agent Name & Telephone #
Insurance Type:
Personal
Auto
Health
Home
5.
PERSONAL
Name of Each Person Injured
Date of Birth
INJURY
INFORMATION
Injured Person Address
Telephone # of Injured Person
Employer, Parent or Guardian Name and Address
Name of Health Insurance Carrier
Phone #
Address of Health Insurance Carrier
Policy #
Nature and Extent of Personal Injury
Name and Address of Medical Service Provider
Phone #
6.
PROPERTY
Owner of Damaged Property
Property Owner’s Social Security #
DAMAGE
Phone #
INFORMATION
Owner Address
City
Zip Code
List all items that were damaged or destroyed
Original Vendor, purchase date, & purchase price
Vendor phone #
Original Vendor, purchase date, & purchase price
Vendor phone #
Original Vendor, purchase date & purchase price
Vendor phone #
Owner’s estimate of total cost to repair/replace damaged items
1
Name and Address
Phone #
Name and Address
Phone #
7.
WITNESSES
Name and Address
Phone #
8.
DESCRIPTION OF
THE INCIDENT
Name and Address of Policy Agency to Whom Incident Was Reported (if any)
Date Reported
9.
OTHER
PERTINENT
INFORMATION
Printed Name of Foster Parent
Foster parent ID #
10. SIGNATURE
Foster Parent Signature
Licensed?
Yes
No
Home of Relative?
Yes
No
Date
11. CASE WORKER
I hereby certify that I have observed the damages or injuries herein and that the above description of the damages or injuries is:
CERTIFICATION
accurate and I support this claim.
not accurate and I do not support this claim
Name of Case Worker’s Agency
Printed Name of Case Worker
Case Worker’s Phone #
Signature
Date
Please attach all receipts, estimates and insurance claim statements for each item, injury or service claimed above.
2
INSTRUCTIONS
FOSTER CHILD DAMAGE REIMBURSEMENT COVERAGE CLAIM FORM
1.
FOSTER PARENT
Please provide the name, address, home and cell phone numbers with area code, and email address of the foster parent.
2.
FOSTER CHILD & CASE WORKER
Provide the name date of birth and DCFS ID number of the foster child who caused the damage or injury. Also include the name of
the child’s case worker and the name, address & telephone number of their office.
3.
INCIDENT DATE & LOCATION
Give the day, month, year, time, and the complete address and location where the incident occurred.
4.
CLAIMANT IDENTITY & CLAIMANT INSURANCE PROVIDER
Provide the names, addresses, telephone and insurance policy numbers for the insurance providers the claimant currently has in force,
including employers’ or school insurance. Attach proof that a claim was submitted to the insurance carriers and a copy of their
disposition. Include the social security number of the claimant.
5.
PERSONAL INJURY INFORMATION
Please give complete information on each party who suffered an injury including their contact information and social security number.
If that party has an applicable insurance carrier, give the carrier’s name, address, phone number and the injured policy number. Give
the name, address and phone number of the doctor, hospital, ambulance service, or clinic that provided services to the injured party.
6.
PROPERTY DAMAGE INFORMATION
Please name each item damaged or destroyed and provide documentation of original vendor, purchase date; and purchase price for
each item, and at least two estimates of costs to repair or replace from established firms or businesses, along with the claim form when
submitted. Also p lease provide the name, address and phone number of the firms which gave the estimates. Please provide the name,
address, telephone, and social security number of the owner of the damaged property.
7.
WITNESSES
Please provide name, address and phone number, along with other information on any witness to the incident.
8.
DESCRIPTION OF INCIDENT
Use another sheet of paper if necessary. Be as specific as possible. Please give the time, date, street addresses, name of everyone
present and as accurate a description as possible of the incident, including what happened, when, where, why, and who caused what
injury or damage to whom. Include the contact information for the police department that was contacted as well.
9.
OTHER PERTINENT INFORMATION
Provide any other information you feel is pertinent to the claim. Please include the name and address of the case worker and social
service agency or fire department to whom the incident was reported.
10.
SIGNATURE
The foster parent of the child who damaged things must sign the form, enter their foster parent ID number, date, and return it to the
child’s case worker. He or she must indicate if they are licensed and/or registered as home of relative.
11.
CASE WORKER CERTIFICATION
The child’s DCFS or POS case worker must review the claim form and mark the appropriate box, sign and date it, and send it to the
th
FCDRP Coordinator, Department of Children and Family Services, 100 W. Randolph, 6
Floor, Chicago, Illinois 60601.
3
Page of 3