State of Illinois

Department of Children and Family Services

 

 Rationale for Not Submitting a License Renewal Application

 

 

Licensee:                                                                                                                                             

 

Licensee:                                                                                                                                             

 

Address:                                                                                                                                              

 

                                                                                                                                                           

                                                (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.