Day Care Service Application Worker Verification Checklist Instructions

Check this box if the applicant meets the specified criteria for eligibility for requested day care services, including providing required employment-related documentation.

Check this box if the Current Rate Certification form has been completed by Day Care Providers who are identified as licensed centers, licensed day care homes or licensed-exempt centers/facilities, and a current one is not already on file in the regional Day Care Office.

Check this box if sufficient written clinical documentation is being submitted for a youth in care, 13 years or older, which describes a clinical diagnosis and supports the need for day care.

Check this box if an on-site visit was conducted and the CFS 2003-On-Site Visit License Exempt and Unlicensed Day Care Provider form was completed and submitted with the day care service application. Fill only if 'Check Box6' is a license-exempt facility operator/owner/employee or an (related/unrelated) unlicensed individual.

Check this box if the CFS 2000 Day Care Service Eligibility Application was completed and the DCFS Fingerprint Search System database check was performed for the day care provider and all household members. Fill only if 'Check Box6' is a license-exempt facility operator/owner/employee or an (related/unrelated) unlicensed individual.

Check this box if both fingerprinting through a Department-authorized vendor and the CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care have been ensured for unrelated/unlicensed day care providers. Fill only if 'Check Box6' is a license-exempt facility operator/owner/employee or an (related/unrelated) unlicensed individual.

Check this box if the New Day Care Provider has completed and attached a signed copy of the IRS W-9 form to the Day Care Service Eligibility Application.

Check this box if, for all other protective/family maintenance day care service applications, you have verified that the necessary SACWIS Family Service Plan documents or CFS 1441 - Safety Plan have been attached, or will be provided as specified if the plan is urgent and not yet completed.

Check this box if an on-site visit has been conducted and the CFS 2003-On-Site Visit License Exempt and Unlicensed Day Care Provider form has been completed and submitted with the day care service application. Fill only if 'Check Box6' is a related/unlicensed day care provider.

Check this box if fingerprinting for the provider has been completed through a Department-authorized vendor.

Check this box if the CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care has been completed.

Check this box if the date of submission for the CFS 718-D and fingerprint receipt to the Department's Background Check Unit (BCU) has been documented on the CFS 2000 - Part III/Section (B).

Check this box if all questions on Part I, Part II, and Part III of this application have been appropriately answered or marked N/A.

Check this box if all required documentation has been photocopied and attached to the application.