Form CFS2000 "Day Care Service Eligibility Application" - Illinois

What Is Form CFS2000?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Illinois Department of Children and Family Services;
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  • Fill out the form in our online filing application.

Download a fillable version of Form CFS2000 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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CFS 2000
Rev 7/2019
State of Illinois
Department of Children and Family Services
DAY CARE SERVICE ELIGIBILITY APPLICATION
COVER PAGE
The DCFS/POS caseworker/investigator has the responsibility to ensure:
Completion of each section of the application and attachment of all support documentation as requested. Incomplete applications
will be placed on hold/denied/or returned to the DCFS/POS case worker for completion and re-submission;
A fully completed application is submitted to the regional Day Care Eligibility Office for approval. A completed application includes all
required supportive documentation. (Caseworker/Investigator responsibility);
Verification that Applicant(s) does not qualify for any other publicly funded child care (e.g. Head Start, public school, pre-kindergarten,
IDHS/Action For Children/local CCR &R Subsidized Child Care);
Assisting the Applicant(s) and Day Care Provider to complete and submit as part of the application packet Part I & Part II;
If the Day Care Provider is unlicensed/or is a license-exempt facility , complete and submit as part of the application packet,
Part III – Section (B), & the CFS 2003. Also, unrelated child daycare providers are required to be fingerprinted and complete the
CFS 718-D Authorization for Background Check (CANTS/Sex Offender Registry/FBI checks)
Immediate notification of any application changes to the regional Day Care office which may affect the status of day care.
For Open Intact Family Services Cases*, the Department shall provide child care for:
Intact families with an open case and whose child/children are under the age of 5, protective need has been assessed, and that day care
has been/will be identified in the service plan as a needed resource for safety reasons; or,
Intact families with an open case and whose child/children are 5 years of age and older and whose parents are working outside the home
or who are participating in employment training or educational programs outside the home that are approved by the Department and any
other means of day care services/pre-school are not available or appropriate (a list of other services attempted should be attached as
documentation).
PRIMARY APPLICANT’S NAME:
Family ID# (Assigned by Day Care office):
DCFS Region:
TYPE OF DAY CARE REQUESTED:
DCFS/POS AGENCY OFFICE INFORMATION
Foster Parent Employment-related Day Care
WORKER NAME
ID NUMBER
Teen Parent Education or Employment-related Day Care
(school and/or employment/skills training)
AGENCY NAME
Protective/Family Maintenance Day Care
Open intact
family*
Family Reunification
STREET
Foster Care
Subsidized Adoptive Parent/Guardian –
CITY
STATE
ZIPCODE
Employment-related Day Care
Therapeutic Day Care (Foster Care)
TELEPHONE NUMBER & EXT #
FAX NUMBER
(Refer to Procedures 302.330 and 359.54
EMAIL ADDRESS
for day care service eligibility guidelines)
We hereby certify to the best of our knowledge and belief, the information contained in this application and
supporting documentation is true, accurate, and complete. (Both worker and supervisor’s names and signatures are
required):
DCFS/POS WORKER NAME (Printed)
DCFS/POS SUPERVISOR NAME (Printed)
DCFS/POS WORKER (Signature)
DATE
DCFS SUPERVISOR (Signature)
DATE
CFS 2000
Rev 7/2019
State of Illinois
Department of Children and Family Services
DAY CARE SERVICE ELIGIBILITY APPLICATION
COVER PAGE
The DCFS/POS caseworker/investigator has the responsibility to ensure:
Completion of each section of the application and attachment of all support documentation as requested. Incomplete applications
will be placed on hold/denied/or returned to the DCFS/POS case worker for completion and re-submission;
A fully completed application is submitted to the regional Day Care Eligibility Office for approval. A completed application includes all
required supportive documentation. (Caseworker/Investigator responsibility);
Verification that Applicant(s) does not qualify for any other publicly funded child care (e.g. Head Start, public school, pre-kindergarten,
IDHS/Action For Children/local CCR &R Subsidized Child Care);
Assisting the Applicant(s) and Day Care Provider to complete and submit as part of the application packet Part I & Part II;
If the Day Care Provider is unlicensed/or is a license-exempt facility , complete and submit as part of the application packet,
Part III – Section (B), & the CFS 2003. Also, unrelated child daycare providers are required to be fingerprinted and complete the
CFS 718-D Authorization for Background Check (CANTS/Sex Offender Registry/FBI checks)
Immediate notification of any application changes to the regional Day Care office which may affect the status of day care.
For Open Intact Family Services Cases*, the Department shall provide child care for:
Intact families with an open case and whose child/children are under the age of 5, protective need has been assessed, and that day care
has been/will be identified in the service plan as a needed resource for safety reasons; or,
Intact families with an open case and whose child/children are 5 years of age and older and whose parents are working outside the home
or who are participating in employment training or educational programs outside the home that are approved by the Department and any
other means of day care services/pre-school are not available or appropriate (a list of other services attempted should be attached as
documentation).
PRIMARY APPLICANT’S NAME:
Family ID# (Assigned by Day Care office):
DCFS Region:
TYPE OF DAY CARE REQUESTED:
DCFS/POS AGENCY OFFICE INFORMATION
Foster Parent Employment-related Day Care
WORKER NAME
ID NUMBER
Teen Parent Education or Employment-related Day Care
(school and/or employment/skills training)
AGENCY NAME
Protective/Family Maintenance Day Care
Open intact
family*
Family Reunification
STREET
Foster Care
Subsidized Adoptive Parent/Guardian –
CITY
STATE
ZIPCODE
Employment-related Day Care
Therapeutic Day Care (Foster Care)
TELEPHONE NUMBER & EXT #
FAX NUMBER
(Refer to Procedures 302.330 and 359.54
EMAIL ADDRESS
for day care service eligibility guidelines)
We hereby certify to the best of our knowledge and belief, the information contained in this application and
supporting documentation is true, accurate, and complete. (Both worker and supervisor’s names and signatures are
required):
DCFS/POS WORKER NAME (Printed)
DCFS/POS SUPERVISOR NAME (Printed)
DCFS/POS WORKER (Signature)
DATE
DCFS SUPERVISOR (Signature)
DATE
CFS 2000
Page 2 of 6
PART I
This section should be completed by the parent, foster parent, teen parent, adoptive parent, guardian or relative caregiver. Worker assistance
should be provided if necessary. (N/A for answers that do not apply)
REASON FOR APPLICATION (Check all that apply)
Initial Day Care Service Eligibility application
Parent/caregiver address change
Change of Day Care Provider
Request for secondary provider (written justification from the caseworker is needed)
Add child(ren) to existing Day Care Service application
(A) PRIMARY APPLICANT’S INFORMATION
Primary 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
Daytime phone number
SSN (last four digits)
Cell phone number
Email address
SSN (last four digits)
Marital Status:
Single
Married
Legal Civil Union
Legally Separated
Legally Divorced
Widowed
PRIMARY APPLICANT’S EMPLOYMENT/SCHOOL/TRAINING INFORMATION
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)
Employer/Company Name/Dept.
Phone number (Ext)
School/Institution Name
Phone (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
My employment/school/training schedule varies
(Please explain on separate sheet. Applicant may also be required to provide written verification from employer/school/training program)
CFS 2000
Page 3 of 6
(B) CO-APPLICANT’S 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 (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
WORK
SCHOOL
My employment/school/training schedule varies.
(Please explain on separate sheet. Applicant may also be required to provide written verification from employer/school/training program)
(C) APPLICANT(S) CERTIFICATIONS
By checking these boxes, the applicant(s) certifies that these statements are true, correct, and complete.
The child(ren) is(are) current on all immunizations and verification is on file with the Day Care Provider (if
applicable- licensed center, home or license-exempt facility).
A review of the facility/home has been completed and I/we agree that it is a safe environment.
Written notification has been given to the Day Care Provider listing anyone, other than myself, authorized to
pick up the child(ren).
An emergency phone number, written consent for medical care and for dispensing prescription medication has
been given to the Day Care Provider.
The name and telephone number of the child’s or family physician is on file with the Day Care Provider.
The information provided on this document is true, complete, and correct.
I/we am/are responsible for the service provided to the child(ren).
I/we will notify the Department’s Regional Day Care Service Unit of any change in Day Care arrangements.
I/we hereby certify to the above statements and further certify that, to the best of my/our knowledge and
belief, the information provided in the application and supporting documentation is true, accurate, and
complete. I/we understand that the information provided will be disclosed only for administration
purposes and that I/we may be asked to verify the information I/we have provided. If the information is
found to be falsified, DCFS reserves the right to recoup funds and/or prosecute. I/we understand that I/we
have the right to appeal the outcome or decision and to have a fair hearing of a grievance.
PRIMARY APPLICANT’S SIGNATURE
DATE
CO-APPLICANT’S SIGNATURE
DATE
CFS 2000
Page 4 of 6
PART II
(A) CHILD(REN) FOR WHOM DAY CARE SERVICES ARE BEING REQUESTED
(Please provide the following information for each child in need of day care services. If additional children, please duplicate
this page and provide the requested information)
END
Social Security
DCFS Case ID
START DATE
Child’s name (Last, First)
Date of Birth
Relationship to Applicant
DATE
#
Number
(if known)
(if known)
(B) DAY CARE SERVICE ARRANGEMENTS
TO BE COMPLETED BY THE PRIMARY APPLICANT OR CASEWORKER/INVESTIGATOR
.
Please complete the following for each child considered for day care services. If additional children, please duplicate this page and provide information
st
nd
rd
1
Child
2
Child
3
Child
Child’s Name (Last, First):
Number of days of care per week:
Number of hours of care per day:
Enter the time child will be cared for daily.
FROM:
am
pm
FROM:
am
pm
FROM:
am
pm
Also, check one below:
Year round
School year only
TO:
am
pm
TO:
am
pm
TO:
am
pm
School break only
Summer only
Other (explain)___________________
How much will/does the day care provider
charge daily?
$
/per day
$
/per day
$
/per day
th
th
th
4
Child
5
Child
6
Child
Child’s Name (Last, First):
Number of days of care per week:
Number of hours of care per day:
Enter the time child will be cared for daily.
FROM:
am
pm
FROM:
am
pm
Also, check one below:
FROM:
am
pm
Year round
School year only
TO:
am
pm
TO:
am
pm
School break only
Summer only
TO:
am
pm
Other (explain)___________________
How much will/does the day care provider
charge daily?
$
/per day
$
/per day
$
/per day
CFS 2000
Page 5 of 6
PART III
(A) DAY CARE SERVICE PROVIDER INFORMATION
TO BE COMPLETED BY THE DAY CARE SERVICE PROVIDER and ASSIGNED WORKER Please complete each line. (N/A for answers that do not apply)
NOTE: If you are a licensed day care provider, your Tax ID # (SSN or FEIN) must match your day care license application information.
Facility/Provider’s Name:
Social Security #:
Street address:
FEIN:
City/State/Zip:
County:
Telephone
Fax
number:
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)
Month
Day
Year
DAY CARE TYPE: (Check One)
(Please Note: Out-of-state, licensed day care centers & homes must attach copy of current day care license)
1.
LICENSED DAY CARE CENTER
DCFS DCC LICENSE #:
Expiration Date:
2.
LICENSED DAY CARE HOME
DCFS DCH LICENSE #:
Expiration Date:
(Please note: No more than 12 unrelated children under the age of 12 may be cared for, including the provider’s own children.)
3.
LICENSED GROUP DAY CARE HOME DCFS GDCH LICENSE #:
Expiration Date:
(Please note: No more than 16 unrelated children under the age of 12 may be cared for, including the provider’s own children.)
4.
DAY CARE CENTER EXEMPT FROM LICENSING.
Provider ID # (if known):
(Note: A verification letter (of facility’s day care exemption status) from DCFS Licensing office must be attached or on file in Day Care Office.)
DAY CARE HOME - UNLICENSED:
(Please Note: No more than three unrelated children under the age of 12 may be cared for, including the provider’s own children)
A.
NON-RELATIVE - Care provided in the home of the provider.
Provider ID #:
B.
RELATIVE - Care provided in the home of a relative (related to child).
Provider ID#:
C.
RELATIVE - Care provided in the home of the child by a relative.
Provider ID#:
D.
NON-RELATIVE - Care provided in the home of the child by a non-relative. Provider ID#:
DAY CARE HOME NETWORK – Contracts with licensed day care home providers. Provider ID#:
E.
PLEASE NOTE:
ALL Day Care providers are required to complete a current DCFS Provider Certifications form (SECTION B of this application).
If you, as a Day Care provider, identify under provider type A, B, C, or D, the child’s Caseworker or Investigator is required to contact
you to complete the following background checks prior to day care services beginning:
Unrelated/Unlicensed Day Care Providers
o
Fingerprinting (through a Department-authorized vendor);
o
CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care.
On the CFS 2000 – Part III/Section (B), the worker or supervisor will document the date when the CFS 718-D (CANTS, SOR
o
and FBI background checks) and fingerprint receipt were submitted to the Department’s Background Check Unit (BCU) for
processing.
The caseworker and/or supervisor will document the potential day care service provider’s final result’s finding in the child’s
o
case file.
Date unrelated/unlicensed day care provider’s Fingerprint receipt and CFS 718-D submitted to Background Check Unit:
Date unrelated/unlicensed day care provider’s full background history check results provided to Worker:
Related/Unlicensed Day Care Providers
o
For related/unlicensed day care providers, a SACWIS system background check (CANTS and SOR) is required.
On the CFS 2000 – Part III/Section (B), the worker or supervisor will document the date when the SACWIS-based
o
CANTS/SOR checks were completed.
Date related/unlicensed day care provider’s SACWIS-based background completed with results:
Page of 6