Form CFS2000-R "Day Care Services - Eligibility Redetermination Application" - Illinois

What Is Form CFS2000-R?

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 CFS2000-R 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 CFS2000-R "Day Care Services - Eligibility Redetermination Application" - Illinois

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CFS 2000 – R
12/2015
State of Illinois
Department of Children and Family Services
DAY CARE SERVICES - ELIGIBILITY REDETERMINATION APPLICATION
Eligibility Redetermination Application Type:
Foster Care/ Employment-related
Foster Care/ Family Maintenance
Subsidized Adoption/Legal Guardianship
Teen Parent
Protective/Intact Family Services/Teen Parent
(school/employment-related)
(not employment-related)
DAY CARE FAMILY ID#:
APPLICANT INFORMATION (Please print)
Co-APPLICANT INFORMATION (Please print)
Applicant Name (Last, First)
Co-applicant Name (Last, First)
Residence Address
Co-applicant Daytime phone number
City
State
Zip Code
Co-applicant cell phone number
Mailing Address (if different than residence)
Email address
SSN
Daytime phone number
(last four digits)
Cell phone number
Email address
SSN
(last four digits)
Marital Status:
Single
Married
Legal Civil Union
Legally Separated
Legally Divorced
Widowed
Applicant Employment/School/Training Information:
PLEASE NOTE: Refer to the attached letter for required documentation in order to complete the Day Care Services – Eligibility
Redetermination Application.
If employed, please provide the following information:
If you attend employment training, list the following information:
(If a teen parent list school or GED Program Information below)
Employer/Company Name/Dept.
Phone number (ext)
School/Institution Name
Phone Number (ext)
Employment/Office Address
Site Address
City
State
Zip Code
City
State
Zip Code
Applicant - List employment/school/training schedule (from – to):
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
WORK
SCHOOL
CFS 2000 – R
12/2015
State of Illinois
Department of Children and Family Services
DAY CARE SERVICES - ELIGIBILITY REDETERMINATION APPLICATION
Eligibility Redetermination Application Type:
Foster Care/ Employment-related
Foster Care/ Family Maintenance
Subsidized Adoption/Legal Guardianship
Teen Parent
Protective/Intact Family Services/Teen Parent
(school/employment-related)
(not employment-related)
DAY CARE FAMILY ID#:
APPLICANT INFORMATION (Please print)
Co-APPLICANT INFORMATION (Please print)
Applicant Name (Last, First)
Co-applicant Name (Last, First)
Residence Address
Co-applicant Daytime phone number
City
State
Zip Code
Co-applicant cell phone number
Mailing Address (if different than residence)
Email address
SSN
Daytime phone number
(last four digits)
Cell phone number
Email address
SSN
(last four digits)
Marital Status:
Single
Married
Legal Civil Union
Legally Separated
Legally Divorced
Widowed
Applicant Employment/School/Training Information:
PLEASE NOTE: Refer to the attached letter for required documentation in order to complete the Day Care Services – Eligibility
Redetermination Application.
If employed, please provide the following information:
If you attend employment training, list the following information:
(If a teen parent list school or GED Program Information below)
Employer/Company Name/Dept.
Phone number (ext)
School/Institution Name
Phone Number (ext)
Employment/Office Address
Site Address
City
State
Zip Code
City
State
Zip Code
Applicant - List employment/school/training schedule (from – to):
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
WORK
SCHOOL
Co-Applicant Employment/School/Training Information
If employed, please provide the following:
If you attend employment training, please provide the following:
(
)
If a teen parent list school or GED Program Information below
Employer/Company Name/Dept.
Phone number (ext)
School/Institution Name
Phone Number (ext)
Employment/Office Address
Site Address
City
State
Zip Code
City
State
Zip Code
Co-applicant - List employment/school/training schedule (from – to):
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
(from – to)
WORK
SCHOOL
CHILD(REN) FOR WHOM DAY CARE SERVICES ARE BEING REQUESTED
(Please provide the following information for each child considered for day care services)
START
Social
DCFS Case ID
Relationship to
END DATE
Child’s name (Last, First)
Date of Birth
DATE
Security #
Number
Applicant
(known/requested)
(if known)
For Day Care for a child 13 years or older: There is appropriate documentation in the child’s case file (a copy of which must be submitted with
this form by the worker), which supports the need for Day Care.
CURRENT DAY CARE PROVIDER INFORMATION
Facility/Provider’s Name:
Social Security #:
Street address:
FEIN:
City/State/Zip:
County:
Telephone number:
Email:
Mailing Address (if different):
City:
State:
Zip code:
Date of Birth:
/
/
(If an individual day care provider, must be 18 years old or older)
CURRENT DAY CARE SERVICE ARRANGEMENT
:
Day
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Time
I hereby certify to the above statements and further certify that, to the best of my knowledge and belief, the information provided is true,
correct, and complete. I understand that the information provided will be disclosed only for administration purposes and that I may be asked
to verify the information I have provided. I understand that I have the right to appeal and to have a fair hearing of a grievance.
APPLICANT’S SIGNATURE
DATE
CO-APPLICANT’S SIGNATURE
DATE
DCFS/POS Caseworker’s signature
DATE
DCFS/POS Supervisor’s signature
DATE
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