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2. 

4. A “community residence” includes occupancies, such as community residential alternatives/facilities, halfway houses, rehabilitation/shelter homes, community integrated living arrangements, and transition facilities that are generally licensed by the Illinois Department of Human Services or the Department of Children and Family Services. The types of residents living in these facilities are varied and are generally those needing assistance in their everyday living requirements.

   Please provide the following information and documentation from the state of Illinois approving or confirming compliance with the state requirements for the community residences (i.e., licensure, state fire marshal inspection, Department of Health Services facility criteria, etc.).¹ 

6. Name of Organization*
8. Organization Management Contact Name*
10. Phone Number*
11. Email*
13. Address 1:*
14. Address 2:
16. City:*
17. State:*
18. Zip:*
20. Number of Residents*
    -- Select One --123456
21. Year Established*
23. Additional Information

    Please provide any pertinent information that should be noted about the community residence.

25. Floor Plan Layout*
26. Other
28. Other
29. Other

33. ¹These may include, but are not limited to, state regulations, such as 77 Ill.Admin.Code 2060.509 and/or the Illinois State Fire Marshal requirements for residential board and care facilities.  

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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field