Form IL444-2998 "Approved Representative Consent Form" - Illinois

What Is Form IL444-2998?

This is a legal form that was released by the Illinois Department of Human 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, 1999;
  • The latest edition provided by the Illinois Department of Human 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 IL444-2998 by clicking the link below or browse more documents and templates provided by the Illinois Department of Human Services.

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Download Form IL444-2998 "Approved Representative Consent Form" - Illinois

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State of Illinois
1 (PERMANENT)
Department of Human Services
APPROVED REPRESENTATIVE CONSENT FORM
APPROVED REPRESENTATIVE'S INFORMATION (PLEASE PRINT LEGIBLY OR TYPE)
Name:
Address:
City:
State:
Zip Code:
Telephone Number:
CLIENT SECTION
I want the person named above to apply for cash, medical and/or Food Stamp benefits for me and/or my family. I understand
that I am still responsible for the information that my representative gives to the Department.
Client's Signature (or mark):
Signature of Witness
(if client signed with a mark):
Date:
REPRESENTATIVE SECTION
I have talked to the client about why they are signing this form. I (or the company I represent) will submit to the Illinois
Department of Human Services a request for cash, medical, and/or Food Stamp benefits on their behalf. I have also told this
client that DHS needs to have certain facts to make a correct decision on their eligibility for benefits.
I have told the client that they need to cooperate with DHS to obtain any needed verification(s) for the eligibility decision.
Representative's Signature:
Relationship to Client:
Print Form
Reset Form
IL 444-2998 (R-9-99)
Page 1 of 1
State of Illinois
1 (PERMANENT)
Department of Human Services
APPROVED REPRESENTATIVE CONSENT FORM
APPROVED REPRESENTATIVE'S INFORMATION (PLEASE PRINT LEGIBLY OR TYPE)
Name:
Address:
City:
State:
Zip Code:
Telephone Number:
CLIENT SECTION
I want the person named above to apply for cash, medical and/or Food Stamp benefits for me and/or my family. I understand
that I am still responsible for the information that my representative gives to the Department.
Client's Signature (or mark):
Signature of Witness
(if client signed with a mark):
Date:
REPRESENTATIVE SECTION
I have talked to the client about why they are signing this form. I (or the company I represent) will submit to the Illinois
Department of Human Services a request for cash, medical, and/or Food Stamp benefits on their behalf. I have also told this
client that DHS needs to have certain facts to make a correct decision on their eligibility for benefits.
I have told the client that they need to cooperate with DHS to obtain any needed verification(s) for the eligibility decision.
Representative's Signature:
Relationship to Client:
Print Form
Reset Form
IL 444-2998 (R-9-99)
Page 1 of 1