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Illinois Department of Human Services
Michelle R.B. Saddler, Secretary
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  1. DHS
  2. for Providers
  3. Contracts
  4. FY13 CSA Attachments and Program Manuals
  5. TANF Employment & Training Program Manual

IX. Forms

The Provider and FCRC staff will use various forms provided by the Department to report and maintain accurate records of each client's activities, hours completed, attendance, progress, etc.

  • Referral Form IL444-2151 (pdf)
  • Change/Progress Report Form IL444-2151A (pdf)
  • TANF Responsibility and Services Plan Form IL444-4003 English (pdf)
  • TANF Responsibility and Services Plan Form IL444-4003S Spanish (pdf)
  • Responsibility and Services Plan Attendance and Activity Report Form IL444-4006 (pdf)
  • Work Experience/Work First/Community Service Worksheet Form IL444-4044 (pdf)
  • Employment and Training Participant List Form IL444-4333 (pdf)
  • Employment and Training Staffing Form IL444-4334 (pdf)
  • Reconciliation Appointment Notice Form IL444-2846 (pdf)
  • Reconciliation Agreement Form IL444-2846A (pdf)
  • Child Care Application Form IL444-3455 (pdf) 
  • Child Care Application Form IL444-3455S Spanish (pdf)
  • Resource Connections Form IL444-4004 (pdf) 
  • Resource Connections Form IL444-4004S Spanish (pdf)
  • First Notice Regarding Non-Cooperation with Work First/Work Experience (Form 4125)
  • Second Notice Regarding Non-Cooperation with Work First/Work Experience (Form 4126)
  • Work First/Work Experience Agreement Form IL444-4484 (pdf)
  • Work First/Work Experience Agreement - Provider/Contractor Form IL444-4484C (pdf)

Related Links

  • I. Introduction
  • II. Vendor/Provider Types
  • III. Countable Work Activites Defined and Explained
  • IV. Hours Engaged in Work/Work-Like Activities
  • V. Provider/Provider Responsibilities
  • VI. Department Responsibilities
  • VII. Program Monitoring
  • VIII. Billing Instructions
  • IX. Forms
  • X. Provider Management Policies and Procedures
  • XI. Costs and Payments - Exhibit C
  • XII. Fiscal
  • XIII. Deliverables - Exhibit B and Budgets
  • XIV. Glossary
  • Attachment I - Transportation
  • Attachment II - Child Care
  • Attachment III - State Authoritative Sources

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