Form CFS597-R "Application for Foster Family Home License for Relative Caregivers" - Illinois

What Is Form CFS597-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 September 1, 2012;
  • 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 printable version of Form CFS597-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 CFS597-R "Application for Foster Family Home License for Relative Caregivers" - Illinois

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CFS 597 R
Complete in duplicate.
State of Illinois
Rev 9/2012
Retain one copy for your file.
Department of Children and Family Services
APPLICATION FOR FOSTER FAMILY HOME
LICENSE FOR RELATIVE CAREGIVERS
DO NOT WRITE IN THIS SPACE – AGENCY USE ONLY
Region/Site/Field
Date Received
Responsible for License
Date Entered
County No.
Supervising Agency No.
DCFS Regional Office
Field Office
Licensed Child Welfare Agency
Name
Street Address
City
Zip
Telephone No.
PLEASE READ INSTRUCTIONS ON THE BACK BEFORE COMPLETING THIS APPLICATION
I. APPLICANT INFORMATION:
Name of Applicants:
A.
Last Name
First Name
Middle
Social Security Number or ITIN Number
B.
Last Name
First Name
Middle
Social Security Number or ITIN Number
Address
No. and Street
City, State and Zip
County
Mailing
Address
No. and Street
City, State and Zip
County
Home
Telephone
Area Code
Number
Work or Cell Number
Work or Cell Number
Applicant A
Applicant B
Area Code
Number
Area Code
Number
Email Address
Email Address
Applicant A
Applicant B
Does Applicant A and/or B speak a language other than English?
No
Yes
If yes indicate:
Applicant A’s Language:
Applicant A’s Proficiency: Bilingual
Fluent
Conversational
Applicant B’s Language:
Applicant B’s Proficiency: Bilingual
Fluent
Conversational
Page 1 of 4
CFS 597 R
Complete in duplicate.
State of Illinois
Rev 9/2012
Retain one copy for your file.
Department of Children and Family Services
APPLICATION FOR FOSTER FAMILY HOME
LICENSE FOR RELATIVE CAREGIVERS
DO NOT WRITE IN THIS SPACE – AGENCY USE ONLY
Region/Site/Field
Date Received
Responsible for License
Date Entered
County No.
Supervising Agency No.
DCFS Regional Office
Field Office
Licensed Child Welfare Agency
Name
Street Address
City
Zip
Telephone No.
PLEASE READ INSTRUCTIONS ON THE BACK BEFORE COMPLETING THIS APPLICATION
I. APPLICANT INFORMATION:
Name of Applicants:
A.
Last Name
First Name
Middle
Social Security Number or ITIN Number
B.
Last Name
First Name
Middle
Social Security Number or ITIN Number
Address
No. and Street
City, State and Zip
County
Mailing
Address
No. and Street
City, State and Zip
County
Home
Telephone
Area Code
Number
Work or Cell Number
Work or Cell Number
Applicant A
Applicant B
Area Code
Number
Area Code
Number
Email Address
Email Address
Applicant A
Applicant B
Does Applicant A and/or B speak a language other than English?
No
Yes
If yes indicate:
Applicant A’s Language:
Applicant A’s Proficiency: Bilingual
Fluent
Conversational
Applicant B’s Language:
Applicant B’s Proficiency: Bilingual
Fluent
Conversational
Page 1 of 4
II. CURRENT AND PREVIOUS LICENSES
1.
Have you ever been convicted for other than a minor traffic violations?
No
Yes
If yes, explain
2.
Are you currently licensed for child care in Illinois?
No
Yes
If yes, give type of license(s) and license(s) No(s)
Name on license(s)
Address on license(s)
3.
Have you ever been licensed for child care outside Illinois?
No
Yes
If yes, give type of license(s) and the license(s) No(s)
Name on license(s)
Address on license(s)
4.
If you are not currently licensed for child care, complete the question below:
Have you ever applied for a child care license?
No
Yes
Was license issued?
No
Yes
Name on license
Address on license
III. HOME—Check any boxes that apply
Do You
Own
Rent
Apartment
Mobile Home
House
Other (Specify)
Do you have landlord approval to care for related children?
Yes
No
Water supply
City
Other (Specify)
Directions for reaching your home:
IV. MARITAL STATUS—Check One Box
Married
Civil Union
(Date)
(Date)
Single
Widowed
Divorced
Legally Separated
V. MEMBERS OF HOUSEHOLD
(include Children, Relatives, Others)
SOCIAL SECURITY or
NAME
RELATIONSHIP
BIRTHDATE
RELIGION
ITIN NUMBER
Applicant A:
Applicant B:
Page 2 of 4
VI. CURRENT EMPLOYMENT
Working
Name of Firm
Address
Title or Position
Hours
to
Applicant A
to
Applicant B
IF APPLICANT(S) WORK OUTSIDE OF HOME, DESCRIBE CHILD CARE PLANS:
VII. REFERENCES:
Persons unrelated to you who know how you care for children
1. Name
Phone
Address
City
Zip Code
2. Name
Phone
Address
City
Zip Code
3. Name
Phone
Address
City
Zip Code
IF EITHER APPLICANT HAS BEEN AN ILLINOIS RESIDENT FOR LESS THAN FIVE
YEARS, INCLUDE TWO REFERENCES FROM THE PREVIOUS RESIDENCE STATE:
4. Name
Phone
Address
City
Zip Code
5. Name
Phone
Address
City
Zip Code
Page 3 of 4
VIII. CERTIFICATION
I (WE), the undersigned, hereby apply for license to operate a foster family home under the Child Care
Act of 1969 as amended. I (WE) declare that, I(WE):
1.
Have received a copy of the standards for foster family homes, have read them and are familiar
with them.
2.
Will be subject to and cooperate with the supervising agency in the licensing process to determine
my/our compliance with licensing standards.
3.
Will be subject to supervision in terms of conformance with minimum standards upon issuance of
a license.
4.
Affirm that the information provided above is true. I(WE) understand that making materially
false statements in order to obtain a license or permit constitutes a Class A misdemeanor and that
I(WE) may be prosecuted for such misconduct.
SIGNATURE(S)
Applicant A
DATE
Applicant B
DATE
INSTRUCTIONS FOR APPLICATION FOR FAMILY HOME LICENSE
Name of Applicant(s)
Enter the name(s) of the person(s) who are applying to be licensed as foster parent(s). Enter the social
security or individual taxpayer identification (ITIN) number of each person listed in the spaces provided.
Address
Enter the complete address of the home’s actual location.
Mailing Address
Use ONLY when the mailing address is different from the actual location of the home.
Telephone Number
Enter the area code and phone number of the home and work telephone if applicable.
All applicants should verify the statements above and sign.
If there is one applicant, he/she must sign the form. If there are joint/married applicants, both must sign.
DCFS is an equal opportunity employer, and
prohibits unlawful discrimination in all of its
programs and/or services.
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