IX. Forms

The Provider and FCRC staff will use various forms provided by the Department to report and maintain accurate records of each customer's activities, hours completed, attendance, progress, etc. These forms can be found on the DHS website site page through the search engine or go to the following URL:  https://www.dhs.state.il.us/page.aspx?item=61585. Those forms that are not available in the Forms Library at the IDHS website (accessible to Providers) have a link built in for your convenience.

•  IL 444-2151 Referral Form (IES)
•  IL 444-2151A Change/Progress Form (IES)
•  IL444-4003 TANF Responsibility and Services Plan Form (English)
•  IL444-4003S TANF Responsibility and Services Plan Form (Spanish)
•  IL444-4044 Work Experience/Work First/Community Service Worksheet
•  IL444-4333 Employment and Training Participant List Form
•  IL444-4334 Employment and Training Staffing Form
•  IL444-2846 Reconciliation Appointment Notice Form (IES)
•  IL444-2846A Reconciliation Agreement Form (IES)
•  IL444-3455 Child Care Application Form (English)
•  IL444-3455S Child Care Application Form (Spanish)
•  IL444-4004 Resource Connections Form (English)
•  IL444-4004S Resource Connections Form (Spanish)
•  IL444-4125 First Notice Regarding Non-Cooperation with Work First/Work Experience
•  IL444-4126 Second Notice Regarding Non-Cooperation with Work First/Work Experience
•  IL444-4484 Work First/Work Experience Agreement
•  IL444-4484C Work First/Work Experience Agreement - Provider/Contractor