Appendix F – Forms information
This Appendix lists information related to forms including the frequency the form is generated and how it’s accessed, whether a Spanish version is available, the outgoing form type, and whether conversion to a PDF is needed.
*All forms that are outgoing from CCMS are system recognizable when incoming. For forms that are incoming only, it is specified in the table below whether they should be system recognizable.
Form name / Frequency/ Access / Spanish version available? / Form Type - Outgoing / Need conversion to PDF? /Eligibility
IL444-3455 - Child Care Application / N/A / Yes / Blank PDF (potentially barcoded for document type) / No
IL444-3455E - Child Care Redetermination / Both / Yes / Barcoded / No
IL444-3455G - Request for a Child Care Provider Change / On-demand daily / Yes / Barcoded / No
Change of Information / On-demand daily / Yes / PDF / No
IL444-4480 Request for Additional Information / On-demand daily / Yes / Barcoded- potentially dynamic / No
IL444-3514 (N-1-11) Wage Verification / On-demand daily / Yes / Blank PDF (potentially barcoded for document type) / No
IL444-4339 – Request for Provider Address Change Information / On-demand daily / Yes / Barcoded / No
IL444-3455A (R-6-03) - Approval of Request for Child Care Payments / On-demand daily
Local Print and Mass Mailing / Yes / N/A / No
IL444-4178 (R-01-02) – Notice of Cancellation of Child Care Payments / On-demand daily
Local Print and Mass Mailing / Yes / N/A / No
IL444-4179 (N-9-98) - Denial of Request for Child Care Payments / On-demand daily
Local Print and Mass Mailing / Yes / N/A / No
IL444-4587 (N-01-01) – Notice of Cancellation of Child Care Payments for Child Age 13 / Monthly / Yes / N/A / N/A
IL444-4590 (N-7-01) - Notice of Provider Cancellation From Child Care Case (Provider Closeout) / On-demand daily
Local Print and Mass Mailing / Yes / N/A / No
Eligibility - LINK ONLY
IL444-3461 License Exempt Child Care Center Self-Certification (Draft 9-07) / N/A / No / Link but recognizable incoming / No
IL444-2790 – Self-Employment Record / N/A / Yes / Link but recognizable incoming / No
IL444-3455F – Request for Reimbursement / N/A / Yes / Link / N/A
IL444-4469 – Child Care Rate Certification Form / On-demand daily Local Print Only / Yes / Link but recognizable incoming / No
W-9 Form / N/A / Yes / Link but recognizable incoming / N/A
IL444-3455B (R-8-07) – Important Parent Co-Payment Information / N/A / Yes / Link. User populated PDF template / No
IL444-4341 (R-4-07) – Child Care Payment Rates for Child Care Centers / N/A / No / Link. User populated PDF template / No
IL444-4343 (R-4-07) – Child Care Payment Rates for Home Based Child Care Providers / N/A / No / Link. User populated PDF template / No
IL444-4773 Child Care Telephone Billing Agreement / On-demand daily Local Print Only / Yes / Link but recognizable incoming / No
IL444-4003 Responsibility and Service Plan / N/A / N/A / Incoming only, recognizable / N/A
IL444-2151 IDHS Referral / N/A / N/A / Incoming only, image / N/A
IL444-2151A Contracted Provider's Referral / N/A / N/A / Incoming only, image / N/A
IL444-2151D Teen Parent Progress Report Form / N/A / N/A / Incoming only, image / N/A
IL444-3085 IDHS Contract Report Notification of Employment / N/A / N/A / Incoming only, image / N/A
Child Care Telephone Billing System Notice / N/A / N/A / Link / N/A
Child Care Telephone Billing Practice Licensed Home / Link
Child Care Telephone Billing Practice Licensed-Exempt Home / N/A / N/A / Link / N/A
IL444-0800 Illinois Debit MasterCard Payment Option Form / N/A / N/A / Link / N/A
Customer Service
IL444-4194 (R-1-11) Authorization for Background Check / On-demand daily / Yes / Barcoded / No
3522 Relative Background Check Letter (Change Order 49649) / On-demand daily / Yes / Barcoded / No
3523 Non-Relative Background Check Letter (Change Order 49649) / On-demand daily / Yes / Barcoded / No
Child Abuse and Neglect Tracking System (CANTS) Batch Routing Document / On-demand daily Local Print Only / No / Barcoded / No
IL444-1900 (R-10-09) Overpayment Referral Form / On-demand daily Local Print Only / No / User populated PDF template, recognizable incoming / No
3518 Overpayment Calculation Sheet / On-demand daily Local Print Only / Yes / N/A / No
IL444-3520 (N-1-11) Child Care Overpayment Letter / On-demand daily Local Print Only / Yes / User populated PDF template / No
IL444-3519 (N-1-11) Provider Overpayment Letter / On-demand daily Local Print Only / Yes / User populated PDF template / No
IL444-3515 (N-1-11) Parent Overpayment Change Letter / On-demand daily Local Print Only / Yes / User populated PDF template / No
IL444-3517 (N-1-11) Provider Overpayment Change Letter / On-demand daily Local Print Only / Yes / User populated PDF template / No
IL444-3516(N-1-11) Rescind of Overpayment / On-demand daily Local Print Only / Yes / User populated PDF template / No
Customer Service - LINK ONLY
4338 Attendance Exemption Request Form (12-2000) / N/A / No / Link / No
IL444-0102 (R-8-03) – Statement of Facts / N/A / Yes / User populated PDF template, recognizable incoming / No
IL444-0065 – Request to Withdraw Appeal / N/A / No / User populated PDF template, recognizable incoming / N/A
IL444-0103 – Notice of Appeal / N/A / Yes / N/A / N/A
IL444-1456 Implementation of Appeal Decision / N/A / No / User populated PDF template / No
4289 Request to Establish Accounts Receivable / N/A / No / Blank PDF / No
3521 License Exempt Center Background Check Letter / N/A / No / N/A / N/A
PIQA
First Non Compliance Letter (Report) / On-demand daily Local Print Only / No / User populated PDF template / No
Second Non Compliance Letter (Report) / On-demand daily Local Print Only / No / User populated PDF template / No
Final Notice of Non Compliance (Report) / On-demand daily Local Print Only / No / User populated PDF template / No
Child Care Fraud Referral Form / On-demand daily Local Print Only / No / Barcoded / No
Monitoring Template / On-demand daily Local Print Only / No / N/A / N/A
Child List by Provider / On-demand daily Local Print Only / No / User populated PDF template / New
Appendix F – Forms information / Page F-4 / Child Care Management System
CCMS-Del-Des-DSD-3 0-Appendix F.doc