State of Illinois

Department of Children and Family Services

REASON FOR EXPIRED 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 my/our renewal application expired and my/our home is now unlicensed.

____ 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.