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REQUEST FOR A CHILD CARE PROVIDER CHANGE

State of Illinois Department of Human Services REQUEST FOR A CHILD care PROVIDER CHANGE CHILD care Case Number: _____ Date: _____ Client: _____ can reach you during the day: Hm: _____ Wk: _____ List a phone number where we _____ _____ ONLY Complete & Return WHEN you CHANGE or ADD Another PROVIDER DO NOT fill this out if you have already sent in a form for your new PROVIDER . If you CHANGE providers or add another PROVIDER , you and your new PROVIDER must complete and SIGN the attached pages. Be sure to also complete this cover page. Return this cover page with the attached pages to the address listed below.

If your new child care provider is not willing to complete the attached pages, call _____ for a parent counselor at the Child Care Resource and Referral agency. They may be able to help you find a new provider. The Department res erves the right to require proof of all information in the attached pages. ...

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