State of Illinois
DEPARTMENT OF CHLDREN AND FAMILY SERVICES
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)
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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)