DCFS Request for Disbursement Instructions
This form contains 36 fields organized into 12 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agency/Office Information | ||
| Agency/Office Name | Text |
Provide the name of the agency or office responsible for this request.
|
| Agency/Office Address | Text |
Enter the full street address of the agency or office.
|
| Agency/Office City | Text |
Provide the city where the agency or office is located.
|
| Agency/Office Zip Code | Text |
Enter the zip code for the agency or office's address.
|
| Agency/Office Fax Area Code | Text |
Provide the area code for the agency or office's fax number.
|
| Agency/Office Fax Number | Text |
Enter the remaining digits of the agency or office's fax number.
|
| Case Worker Telephone | ||
| Case Worker Telephone Area Code | Text |
Please enter the area code for the case worker's telephone number.
|
| Case Worker Telephone Number and Extension | Text |
Please enter the main part of the case worker's telephone number and any extension.
|
| Fifth Item | ||
| Fifth Item Description | Text |
Please provide a detailed description of the fifth item being requested for disbursement.
|
| Fifth Item Cost | Number |
Please provide the cost of the fifth item. Fill only if 'Fifth Item Description' is not empty.
Depends on:
Fifth Item Description
|
| Fifth Item Child Benefit | Text |
Please explain how the fifth item will benefit the child. Fill only if 'Fifth Item Description' is not empty.
Depends on:
Fifth Item Description
|
| First Item | ||
| First Item Description | Text |
Please enter a description of the first item for which disbursement is requested.
|
| First Item Cost | Number |
Please enter the cost of the first item. Fill only if 'First Item Description' is not empty.
Depends on:
First Item Description
|
| First Item Benefit | Text |
Please describe how the first item will benefit the child. Fill only if 'First Item Description' is not empty.
Depends on:
First Item Description
|
| Fourth Item | ||
| Fourth Item Description | Text |
Please enter a description for the fourth item requested.
|
| Fourth Item Cost | Number |
Please enter the cost of the fourth item. Fill only if 'Fourth Item Description' is not empty.
Depends on:
Fourth Item Description
|
| Fourth Item Benefit to Child | Text |
Please explain how the fourth item will benefit the child. Fill only if 'Fourth Item Description' is not empty.
Depends on:
Fourth Item Description
|
| Second Item | ||
| Requested Item | Text |
Please provide a detailed description of the item or service being requested.
|
| Item Cost | Number |
Enter the monetary cost of the item or service. Fill only if 'Requested Item' is not empty.
Depends on:
Requested Item
|
| Child Benefit Explanation | Text |
Explain how the requested item or service will benefit the child. Fill only if 'Requested Item' is not empty.
Depends on:
Requested Item
|
| Sixth Item | ||
| Sixth Item | Text |
Please enter the name or description of the sixth item being requested.
|
| Cost of Sixth Item | Number |
Please enter the cost of the sixth item requested. Fill only if 'Sixth Item' is not empty.
Depends on:
Sixth Item
|
| Benefit of Sixth Item | Text |
Please describe how the sixth item requested will benefit the child. Fill only if 'Sixth Item' is not empty.
Depends on:
Sixth Item
|
| Supervisor Telephone | ||
| Supervisor Telephone Area Code | Text |
Please enter the supervisor's telephone area code.
|
| Supervisor Telephone Number and Extension | Text |
Please enter the supervisor's telephone number and any applicable extension.
|
| Third Item | ||
| Third Item Description | Text |
Please provide a description for the third item.
|
| Third Item Cost | Number |
Please enter the cost for the third item. Fill only if 'Third Item Description' is not empty.
Depends on:
Third Item Description
|
| Third Item Benefit Explanation | Text |
Please explain how the third item will benefit the child. Fill only if 'Third Item Description' is not empty.
Depends on:
Third Item Description
|
| Total Costs | ||
| Text24 | Text | |
| Text25 | Text | |
| Text26 | Text | |
| Vendor Information | ||
| Vendor Name | Text |
Please enter the full name of the vendor.
|
| Vendor Address | Text |
Please enter the street address or P.O. box number of the vendor.
|
| Vendor City, State, and Zip | Text |
Please enter the city, state, and zip code of the vendor.
|
| Ward Information | ||
| Ward's Name | Text |
Please provide the full name of the ward.
|
| DCFS ID Number | Text |
Please provide the DCFS identification number for the ward.
|