PRINT: Last Name/First Name/Middle Initial Provider ID #
Page 1 of 3
Illinois Department of Children and Family Services
AUTHORIZATION FOR BACKGROUND CHECK for Foster Care & Adoption
READ INSTRUCTIONS ON PAGE 2. PRINT ALL INFORMATION ON PAGE 1. SIGN PAGE 1 AND 3.
1
CHECK ONE BOX IN EACH COLUMN IN THE APPLICABLE ROW A or B:
Category of Facility
Specific Type of Application
Person in the Home
A
Foster Care
Initial
Renewal
Relative
Traditional
ICPC
Applicant
Member of Household (ages 13 through 17)*
*Parent/Guardian signature required
Member of Household (age 18 and over)
Youth in Care
B
Adoption
Adopt Only Home
Unlicensed Relative in Illinois
Unlicensed Relative Out of State
For Placement Purposes
For Adoption Purposes
PERSONAL INFORMATION (Please see additions instructions on the back page)
2
Last Name/First Name/Middle Initial
Social Security or ITIN Number __ __ __ - __ __ - __ __ __ __
Maiden and/or Any Names Formerly Used (Last/First/Middle Initial)
I am or will be transporting foster children Yes No
If this statement is yes, list your Drivers License number here:
__ __ __ __ - __ __ __ __ - __ __ __ __
Is this an Illinois Drivers License Number? Yes No
CURRENT ADDRESS, TELEPHONE (when applicable):
Street/Apt.#:
City: State: __ __
Zip Code: __ __ __ __ __ County:
Home Telephone ( __ __ __ ) __ __ __ - __ __ __ __
Cell Phone ( __ __ __ ) __ __ __ - __ __ __ __
Have you lived outside of Illinois in the past 5 years? Yes No
List all previous addresses for the past five (5) years,
including those outside of Illinois. Dates
(Street/Apt.#/City/County/State/Zip Code) From/To
Age
Place of Birth
(City and State)
Citizenship (Country)
USA
Other Specify
Gender
M
F
Height
Ft. In.
Weight
(lbs.)
Hair
(color)
Eye
(color)
Race (Check all that apply)
Ethnicity
(see codes on Page 2)
Native American/Alaskan (Indian or Eskimo)
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Unknown
Declined to Identify
Could not be Verified
AUTHORIZATION /CERTIFICATION BELOW AND ON PAGE 3 MUST BE SIGNED AND DATED
3
Have you ever been indicated as perpetrator in a child abuse/neglect investigation?
Yes No
Have you ever been convicted of a criminal offense, other than a minor traffic violation?
Yes No
I certify that I have read and understood the Authorization/Certification box on the back page of this form.
Signature Date
Parent/Guardian Signature (if applicable) Date
4
TO BE COMPLETED BY SUPERVISING AGENCY
This authorization form will not be processed without completion of this section. The licensing representative must complete the following
Date Fingerprinted:
Full Name of Facility
Provider ID #
Street Address:
City IL ZIP:
Supervising Agency Name:
Provider ID#
Or
DCFS Region/Site/Field
Name of Worker Worker ID#/Phone Number
Name of Supervisor Supervisor ID#/Phone Number
5
BACKGROUND RESULTS AS APPLICABLE
Sex Offender Clearance:
CANTS Clearance:
Illinois State Police Clearance:
FBI Clearance:
Transfer Clearances: SO/CANTS: ISP:
FOR CENTRAL OFFICE OF LICENSING USE
SID# Clear Record
BC-03 Registered:
FBI Sent Out:
Valid Driver's License: Yes __________ No ___________
CFS 718-A
Rev 9/2020
PRINT: Last Name/First Name/Middle Initial Provider ID #
Page 2 of 3
WHO SHOULD USE THIS FORM: This form must be completed by every person age 13 or older as part of an application to operate or reside in a foster
care home. Every person subject to a background check must complete the first three sections identifying the type of facility and what role they will have at
the facility and all personal information. All identifying information must be accurate and complete. The Parent or Guardian’s signature is required if
background check is for a minor.
ADDITIONAL INSTRUCTIONS FOR SECTIONS 2 AND 3 OF THE FRONT PAGE
Name:
Current and all former names used by the individual must be included. If no other names, write “none.”
Social Security,
ITIN or Assigned #.
THIS FORM WILL NOT BE PROCESSED WITHOUT A COMPLETE SOCIAL SECURITY, INDIVIDUAL
TAXPAYER IDENTIFICATION (ITIN) NUMBER OR DEPARTMENT ASSIGNED NUMBER
Address:
Current and all addresses, including county, where the person has lived in the past five years (Indicate if outside of Illinois)
Race:
Enter all race codes that apply.
NA = Native American/Alaskan (Indian or Eskimo)
AS = Asian
BL = Black/African American
PI = Native Hawaiian/Pacific Islander
WH = White
UK = Unknown
DI = Declined to Identify
CV = Could not be Verified
Ethnicity:
Enter the primary Ethnicity
NH = Not Hispanic (NONE)
HS = Hispanic South American
HM = Hispanic Mexican
HP = Hispanic Puerto Rican
HD = Hispanic Spanish Descent
HC = Hispanic Cuban
HA = Hispanic Central American
HN = Hispanic Dominican
HO = Hispanic Other
UK = Unknown
DI = Declined to Identify
CV = Could not be Verified
ADDITIONAL INSTRUCTIONS FOR SECTIONS 4 OF THE FRONT PAGE
Instruction for Left Side -
Date Fingerprinted: Provide the date the individual is fingerprinted
Name of Provider: The full name which appears on the license application or the
license. (DO NOT USE ACRONYMS)
Provider ID #: The Provider ID. (The number which appears on the license
certificate for the facility. Initial Applications will be assigned #
by Background Check Unit.)
Street/City/Zip: The site of licensed facility where person is licensed or
employed.
Instructions for Right Side –
Supervising Agency: Print the name and Provider ID# of Agency which
will supervise the facility
Provider ID #:
DCFS Region/Site/field: The DCFS Region/Site/Field.
Name of the
Worker: Name, ID and phone of the worker
Name of the
Supervisor: Name, ID and phone of the supervisor
The Authorization for Background Check must be submitted to the worker for completion of Section 4 and for forwarding to the DCFS pertinent
Background Check Unit. The worker must check the form for completeness and accuracy, confirm that the person (if age 18 or older) has been
fingerprinted, and verify the correct spelling of names alongside a form of identification, such as a driver’s license or photo ID.
ADDITIONAL INSTRUCTIONS FOR PAGE 3
The ISP/FBI PRIVACY ACT STATEMENT and the AUTHORIZATION/CERTIFICATION on page 3 of this form
must be signed and dated by individuals having a Background Check completed. Individuals being background
checked/fingerprinted have a right to receive a copy of this form.
PRINT: Last Name/First Name/Middle Initial Provider ID #
Page 3 of 3
ISP/FBI PRIVACY ACT STATEMENT
Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28
U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub.
L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary;
however, failure to do so may affect completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-
based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or
otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next
Generation identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other
available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated
information/biometrics in NGI after the completion of this application and while retained, your fingerprints may continue to be compared
against other fingerprints submitted to or retained by NGI.
Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated
information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without
your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal
Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to,
disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing,
security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies;
and agencies responsible for national security or public safety.
Applicant Record Notification: Your fingerprints will be used to check the criminal history records of the FBI. Procedures for obtaining
a copy or change, correction or updating of FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section
16.30 through 16.34 or go to the FBI website at http://www.fbi.gov/about-us/cjis/background-checks.
Signature Date
Parent/Guardian Signature (if applicable) Date
AUTHORIZATION/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 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 20 ILCS 2630/7 of the Criminal Identification Act."
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 Department of Law Enforcement in the conduct of this investigation. I authorize the
Department to periodically search child abuse and neglect history reports to determine whether I have been a perpetrator of an “indicated”
incident of child abuse or neglect pursuant to the Abused and Neglected Child Reporting Act. If I am applying for a foster home license,
I authorize the Department of Children and Family Services to obtain information from those entities to which I had applied for license or
supervision of license, regarding licensing violations or removal of children from my home. If I am or will be a member of a foster family
household and will be transporting foster children, I authorize the Department to conduct periodic checks of my driver’s license and driving
record through the Secretary of State. The child abuse and neglect background check and the criminal history investigation may be used
for considering placement of a related child or an application for licensure. Persons 13-17 years of age signing this form authorize a search
of CANTS and SOR only and are not subject to fingerprinting.
I understand that information obtained as a result of my authorizing this investigation is confidential. Only DCFS shall receive for review
FBI Background check results and upon request the employee, prospective employee or volunteer will be provided a copy. State conviction
information provided by the Department of State Police regarding employees, prospective employees, or volunteers of non-licensed service
providers and child care facilities licensed under this Act shall be provided to the operator of such facility, and, upon request, to the
employee, prospective employee, or volunteer of a child care facility or non-licensed service provider. [225 ILCS 10/4.1]. 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 licensure.
Should you feel that the information on your Illinois State Police record or Federal Bureau of Investigation record is incorrect you may
visit: http://www.ilga.gov/commission/jcar/admincode/020/02001210sections.html for the ISP and http://www.fbi.gov for FBI.
Signature Date
Parent/Guardian Signature (if applicable) Date