Form CFS578-4 "Request to Transfer Licensing Responsibility for Hmr Home" - Illinois

What Is Form CFS578-4?

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 October 1, 2001;
  • 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 CFS578-4 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 CFS578-4 "Request to Transfer Licensing Responsibility for Hmr Home" - Illinois

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CFS 578-4
10/01
State of Illinois
DEPARTMENT OF CHLDREN AND FAMILY SERVICES
Request to Transfer Licensing Responsibility for HMR Home
To:
HMR Coordinator
Re:
Caregivers
Address:
(City)
(Zip Code)
The caregivers have indicated on the CFS 578-1, Confirmation of Interest, that they
are interested in getting licensed.
The caregivers have indicated on the CFS 578-1, Confirmation of Interest, that they
are not interested in getting licensed.
Please remove responsibility for licensing work from this DCFS region or POS agency because
all of this region’s or agency’s children have moved out of this home.
Submitted by:
(Licensing Representative Signature)
(Date)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
To be completed by the HMR Coordinator:
To:
Region or Agency:
The request to transfer responsibility for licensing activities has been granted.
The request to transfer responsibility for licensing activities has been denied. Licensing
responsibility will remain with your region/agency.
because the data system does not confirm that all of your region’s or agency’s
children have been removed from the home; or
there are no longer any children in the home, but the caregivers have indicated
an interest in becoming licensed. Therefore, your region/agency will continue to
be responsible for carrying out licensing activities, although the home will no
longer be tracked as an HMR home.
(HMR Coordinator Signature)
(Date)
CFS 578-4
10/01
State of Illinois
DEPARTMENT OF CHLDREN AND FAMILY SERVICES
Request to Transfer Licensing Responsibility for HMR Home
To:
HMR Coordinator
Re:
Caregivers
Address:
(City)
(Zip Code)
The caregivers have indicated on the CFS 578-1, Confirmation of Interest, that they
are interested in getting licensed.
The caregivers have indicated on the CFS 578-1, Confirmation of Interest, that they
are not interested in getting licensed.
Please remove responsibility for licensing work from this DCFS region or POS agency because
all of this region’s or agency’s children have moved out of this home.
Submitted by:
(Licensing Representative Signature)
(Date)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
To be completed by the HMR Coordinator:
To:
Region or Agency:
The request to transfer responsibility for licensing activities has been granted.
The request to transfer responsibility for licensing activities has been denied. Licensing
responsibility will remain with your region/agency.
because the data system does not confirm that all of your region’s or agency’s
children have been removed from the home; or
there are no longer any children in the home, but the caregivers have indicated
an interest in becoming licensed. Therefore, your region/agency will continue to
be responsible for carrying out licensing activities, although the home will no
longer be tracked as an HMR home.
(HMR Coordinator Signature)
(Date)