1. a) The title, which will be "Authorization for Background Check for Certified Relative Homes".
2. b) A box for the individual completing the form to select if they are the applicant, member of household, or the youth in care.
3. c) A section entitled "Personal Information", which will request the following information:
4. 1) Last name;
5. 2) First name;
6. 3) Middle initial;
7. 4) Maiden and any names formerly used (last, first, middle initial);
8. 5) Current address and telephone number;

9. 6) Social security or ITIN number;

   1. 7) If a person has lived outside of Illinois in the past five years, and if so all the complete addresses for the past five years and the dates lived at each address;
10. 8) Date of birth;
11. 9) Age;
12. 10) Place of birth;
13. 11) Citizenship;
14. 12) Sex;
15. 13) Height;
16. 14) Weight;
17. 15) Hair color;
18. 16) Eye color;
19. 17) Race; and
20. 18) Ethnicity.
21. d) A section with the questions "have you ever been indicated as a perpetrator in a child abuse and neglect investigation" and "have you ever been convicted of a criminal offense, other than a minor traffic violation". The following certification shall appear in this section: "I certify that I have read and understood the Authorization and Certification box on the back page of this form." The certification will have places for the individual to sign and date.
22. e) A section to be completed by the worker at the supervising agency, which requests the following information:
23. 1) Date fingerprinted;
24. 2) Full name of provider;
25. 3) Provider ID number;
26. 4) Provider address;
27. 5) Supervising agency name and provider ID or DCFS region, site, and field;
28. 6) Name of worker;
29. 7) Worker ID and phone number;
30. 8) Name of supervisor; and
31. 9) Supervisor ID and phone number.
32. f) A section to be completed by the Department, which includes the following information:
33. 1) Sex offender clearance;
34. 2) CANTS clearance;
35. 3) Illinois State Police clearance;
36. 4) FBI clearance;
37. 5) SID number;
38. 6) Clear;
39. 7) Record;
40. 8) BC-03 registered; and
41. 9) FBI sent out.

42. g) A section with instructions on how to complete the form.

    1. h) A section for the Illinois State Police and Privacy Act Statement with a place for the individual's signature and date.

    2. i) A section with the following certification: "I hereby authorize the release of any criminal history record information, that may exist, regarding me from any agency, organization, institution, or entity having such information on file. I am aware and understand that my fingerprints may be retained and will be used to check the criminal history record information files of the Illinois State Police and/or the Federal Bureau of Investigation, to include but not limited to civil, criminal and latent fingerprint databases. I also understand that if my photo was taken, my photo may be shared only for employment, certification, or licensing purposes. I further understand that I have the right to challenge any information disseminated from these criminal justice agencies regarding me that may be inaccurate or incomplete pursuant to Title 28 Code of Federal Regulation 16.34 and Chapter 7 of the Criminal Identification Act. [ 20 ILCS 2630/7]

       I authorize the Illinois Department of Children and Family Services to conduct an investigation to determine whether I have ever been charged with a crime and, if so, the disposition of those charges. I authorize the Department to request information and assistance from the U.S. Justice Department and the Illinois Attorney General in the conduct of this investigation. I authorize the Department to periodically search child abuse and neglect registries to determine whether I have been a perpetrator of an "indicated" finding of child abuse or neglect pursuant to the Abused and Neglected Child Reporting Act or other states' relevant laws. I authorize the Department to conduct periodic searches of pertinent sex offender registries. The child abuse and neglect background check, out-of-state child abuse and neglect background check, sex offender search, and the criminal history investigation may be used for considering an application for relative home certification. Authorization for household members 13 through 17 years of age must be obtained to conduct a search of pertinent child abuse/neglect databases and sex offender registries only and are not subject to fingerprinting.

       I understand the information obtained as a result of my authorizing this investigation is confidential. Only the Department shall receive for review FBI background check results, and upon request, I will be provided a copy. I further certify that the information provided on this form is true and correct. I acknowledge that falsification of any information provided above and/or the results of the background check may be full and sufficient grounds to deny the application for certification."

    3. j) A section with directions for contacting the Illinois State Police and/or the FBI if the individual believes that the criminal history information discovered in the background check process is incorrect. The form will direct the individual to ISP's administrative rules (20 Ill. Adm. Code 1210) and to the FBI's website (https://forms.fbi.gov/cjis-ucr/identity-history-summary-checks-review)

To be considered to become a certified relative caregiver, a relative and all other adults living in the home age 18 or older shall complete an authorization for a background check form. Only a Department-issued official form with a CFS number in the top left-hand corner shall satisfy the requirements of 225 ILCS 10/3.4 and this Part. The form shall consist of the following elements: