State of Illinois

DEPARTMENT OF CHLDREN AND FAMILY SERVICES

 

Request to Transfer Licensing Responsibility for HMR Home

 

 

To:        HMR Coordinator

 

Re:                                                                                                                                           Caregivers         

 

Address:                                                                                                                      

 

                                                                                                                                               

                                    (City)                                                                (Zip Code)

 

q          The caregivers have indicated on the CFS 578-1, Confirmation of Interest, that they are interested in getting licensed.

 

q          The caregivers have indicated on the CFS 578-1, Confirmation of Interest, that they are not interested in getting licensed.

 

Please remove responsibility for licensing work from this DCFS region or POS agency because all of this region’s or agency’s children have moved out of this home.

 

Submitted by:

 

                                                                                                                                   

         (Licensing Representative Signature)                                           (Date)

 

 

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

 

To be completed by the HMR Coordinator:

 

To:                                                                                                                                          

 

Region or Agency:                                                                                                                    

 

 

q          The request to transfer responsibility for licensing activities has been granted.

 

q          The request to transfer responsibility for licensing activities has been denied.  Licensing responsibility will remain with your region/agency.

 

____     because the data system does not confirm that all of your region’s or agency’s children have been removed from the home; or

 

____     there are no longer any children in the home, but the caregivers have indicated an interest in becoming licensed. Therefore, your region/agency will continue to be responsible for carrying out licensing activities, although the home will no longer be tracked as an HMR home.

 

                                                                                                                                   

         (HMR Coordinator Signature)                                                      (Date)