State of Illinois Department of Human Services (IDHS) – Bureau of Child Care and Development Child Care Application (Form IL444-3455) Completed Form Examples and Samples
Find clear, filled-out examples of the State of Illinois IDHS Child Care Application (Form IL444-3455). Our samples guide you through completing the form for the Child Care Assistance Program (CCAP) accurately.
IDHS Child Care Application (Form IL444-3455) Example – Single Working Parent
How this form was filled:
This is an example of a completed Illinois Child Care Application for a single working parent with one child. The form details the parent's employment and income, the child's information, and the selected licensed child care provider's details, as required for the Child Care Assistance Program (CCAP).
Information used to fill out the document:
- Applicant Name: Maria Sanchez
- Child's Name: Leo Sanchez
- Child's Date of Birth: 07/15/2023
- Applicant's Marital Status: Single
- Household Size: 2
- Home Address: 456 Maple Ave, Chicago, IL 60622
- Applicant's Employer: The Daily Grind Cafe
- Gross Monthly Income: $2,800
- Work Schedule: Monday - Friday, 8:00 AM - 4:00 PM
- Child Care Provider: Little Sprouts Learning Center
- Provider Type: Licensed Child Care Center
- Provider FEIN: 98-7654321
- Requested Child Care Schedule: Monday - Friday, 7:30 AM - 4:30 PM
- Application Date: 03/10/2026
What this filled form sample shows:
- Parent and Child Information: Clearly lists the applicant and the child requiring care, including dates of birth and social security numbers.
- Household and Marital Status: Correctly identifies the household size and the parent's single status, which is crucial for determining eligibility.
- Employment and Income Details: Provides comprehensive information about the parent's job, work schedule, and gross monthly income, along with employer contact details for verification.
- Child Care Provider Selection: Specifies a licensed child care center, including its name, address, and FEIN, demonstrating a complete provider choice.
- Signed and Dated: The application is properly signed and dated by the parent, certifying the accuracy of the provided information.
Form specifications and details:
| Form Name: | Child Care Application |
| Form Number: | IL444-3455 |
| State: | Illinois |
| Agency: | Department of Human Services (IDHS) – Bureau of Child Care and Development |
| Program: | Child Care Assistance Program (CCAP) |
| Use Case: | Single working parent applying for assistance for one child. |
Created: January 29, 2026 11:43 PM
