You can access this form by clicking on Request for MIS Hardware, Software and Services
Leave the entire block blank (that is Recipient through *Required Estimated Total Cost)
Write as applicable:
"Illinois driver's license will not verify," and then write license number
"Requestor has out-of-state license,"
and then write state and license number
Write in the Justification box: "DHS.G.CIRAS_ISCProviderExternalReporting, Required for reporting."
All fields should be left blank.
Once completed, both pages of the form must be emailed to Sherry.Hinds@illinois.gov
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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