The following is a list of forms used by the Child Care Program. View the form alphabetically by title, numerically by the form number, or by the section of the manual by clicking the appropriate heading. Obtain the form either by clicking the link provided (for PDF) or by contacting the CCR&R.  System Generated forms are not available to the public.

If a link is not working properly, please email DHS.Onenet@illinois.gov so we can repair the link.

Form Number Form Title Manual Number in Which the Form is Mentioned
IL444-0102 (pdf) Statement of Facts
IL444-0102S (pdf) Statement of Facts (spanish)
IL444-0103 (pdf) Notice of Appeal 04.04.01
IL444-0103S (pdf) Notice of Appeal (Spanish) 04.04.01
IL444-1038 Retrieval Request 03.02.01
IL444-1900 (pdf) Overpayment Referral 07.04.01
IL444-2151 Referral for Employment 01.03.03
IL444-2151A Change/Progress Report 01.03.03
IL444-2790 (pdf) Self-Employment Record 01.03.02
IL444-2790S (pdf) Self-Employment Record (Spanish) 01.03.02
IL444-3085 Contract Report Notification of Employment 01.03.03
IL444-3455 (pdf) Child Care Application 01.02.01; 01.04.01; 02.02.02
IL444-3455S (pdf) Child Care Application (Spanish) 02.02.02; 03.01.01
IL444-3455A Approval of Request for Child Care Payments 03.01.01
IL444-3455AS Approval of Request for Child Care Payments, Spanish version 03.01.01
IL444-3455B (pdf) Important Parent Co-payment Information 04.02.01
IL444-3455BS (pdf) Important Parent Co-payment Information(Spanish) 04.02.01
IL444-3455D Important Information for Child Care Providers
IL444-3455E Request for Redetermination 01.03.02; 01.04.01; 02.02.02; 02.09.01
IL444-3455ES Request for Redetermination, Spanish version 02.02.02; 02.09.01; 03.01.01
IL444-3455F Request for Reimbursement 03.01.01; 06.01.02
IL444-3455FS Request for Reimbursement, Spanish version 03.01.01; 06.01.02
IL444-3455G Request for Child Care Provider Change 02.07.02; 02.09.01; 03.01.01
IL444-3455GS Request for Child Care Provider Change, Spanish version 02.07.02; 02.09.01; 03.01.01
IL444-3461 (pdf) License Exempt Child Care Center Self-Certification 05.02.03
IL444-3492A Child Care Certificate Report 06.01.01
IL444-4003 Responsibility and Service Plan 01.03.03
IL444-4178 Notice of Cancellation of Child Care Payments 02.07.01; 03.01.01
IL444-4178S Notice of Cancellation of Child Care Payments, Spanish version 02.07.01; 03.01.01
IL444-4179 Denial of Request for Child Care Payments 02.01.01; 02.02.03; 03.01.01
IL444-4179S Denial of Request for Child Care Payments, Spanish version 02.01.01; 02.02.03; 03.01.01
IL444-4194 Authorization for Background Check 05.03.01
IL444-4338 (pdf) Attendance Exemption Request Form 02.06.01
IL444-4339 (pdf) Request for Provider Address Change
IL444-4339S (pdf) Request for Provider Address Change (Spanish)
IL444-4469 (pdf) Child Care Rate Certification Form 06.05.01
IL444-4469S (pdf) Child Care Rate Certification Form (Spanish)
IL444-4480 Request for Additional Information 02.02.03; 03.01.01
IL444-4480S Request for Additional Information (Spanish) 02.02.03; 03.01.01
IL444-4587 Notice of Cancellation for Child Care Payments for Child Age 13 02.07.01
IL444-4590 Provider Closeout 02.07.02
No form number Additional Address/DBA Form 06.04.01
No form number Authorization for Direct Deposit of Forgery Reimbursement 07.06.01
No form number Child Care Program Referral Information for Investigation 07.05.01
No form number Child Care Rate Certification Form for Contracts
No form number Client Address Change Request
No form number Client Payment Agreement Form 07.04.01
No form number Forged Warrant Affidavit 07.06.01
No form number Forged Warrant Affidavit for State Agencies 07.06.01
No form number Forged Warrant(s) Investigation Claim Form 07.06.01
No form number Provider Payment Agreement Form 07.04.01
No form number Shared Case Form
No form number Shared Case Parent Co-payment Worksheet
No form number Shared Case Schedule
No form number Shared Site/Transfer Case Form
No form number Stop Payment Request 06.04.01
No form number Transfer Case Form
W-9 Request for Taxpayer Identification Number and Certification 05.02.01
W-9 (SP) Request for Taxpayer Identification Number and Certification, Spanish Version 05.02.01