Request Form

Welcome to the on-line form request for the Child Care Assistance Program. All forms requested will be mailed to the address you list within 1-3 business days. If you do not receive the form, please call our office at 1-800-325-5516 or 333-3252. Thank you.

1. Which form are you requesting be sent to you? Forms (other than an application) can only be sent to the parent/guardian on the case.

1. Which form are you requesting be sent to you? Forms (other than an application) can only be sent to the parent/guardian on the case.

Application (for applicants who have not had an active case within the last 30 days)

Application - new baby (when adding a new baby to your case)

Redetermination (must be completed at the end of your eligibility period to continue your case or if your information changes during your eligibility period- i.e. job, marital status, family size, etc.)

Provider Change (if you are changing or adding a child care provider)

Billing Certificate - mailed to the child care provider.

2. We serve 6 counties including Champaign, Douglas, Iroquois, Macon, Piatt, and Vermilion. Which county does the parent reside?

Champaign

Douglas

Iroquois

Macon

Piatt

Vermilion

3. What is the name of the parent?

4. What is your social security number or your case number? This is for the parent or guardian of the case.

5. What is the street address that you want the form sent to? (Must be address of the parent unless you are requesting an application.)

6. What city would you like the form sent to?

7. What is the Zip code to the address?

8. If we have questions, what number can we reach you at?

limited to 25 characters.

Include your email address in your submission to:

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CHILD CARE RESOURCE SERVICE

905 S. Goodwin 314 Bevier Hall Urbana, Illinois 61801

PHONE (217) 333 3252 (800) 325 5516 | EMAIL ccrs@illinois.edu | WEB www.ccrs.illinois.edu

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