State of Illinois

Department of Children and Family Services


 Rationale for Not Submitting a License Renewal Application










                                                (City)                                                                (Zip Code)


Provider ID #:                                                                



Licensing representative  met with me/us on this date and explained the need to document the reasons why I/we did not submit an application to renew my/our foster home license.


____     Training Requirements                                        ____     Medicals


____     Background Checks                                           ____     Physical Plant Issues


____     State Regulatory Oversight


____     I/we have adopted/will adopt the related child(ren) placed with us on

___________ (date).


____     I/we have become/will become the guardian of the related child(ren) placed

with us on ____________ (date).


____     Other (please specify)                                                                                                               







                        (Caregiver Signature)                                 (Date)                                    (SSN)



                        (Caregiver Signature)                                 (Date)                                    (SSN)



Submitted by:                                                                                                                                      

(Licensing Worker Signature)                                                      (Date)




Directions to Licensing Worker:  Fax completed form to HMR Coordinator at 217/782-6446.