Use the following guidelines to complete Form 2355:
Items 1-11, 20-21 - Completion required;
Items 12-19 - Complete if information is available.
Include the information provided by DCFS on HFS 2378B, Request for Cash, Medical, Food Stamps, relating to the status of the child's natural parents and RR contribution. Complete Item 19 to show the type of legal responsibility DCFS has for the child.
Attach or include all financial information supplied by DMHDD concerning the RR(s). Include the following information about the child in Item 19:
Bureau of Fiscal Operations
Cash Management Unit
P.O. Box 19407
Springfield, IL 62794-9407
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
IDHS Office Locator
IDHS Help Line
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