1. PROPOSED SERVICE AREA Put a check mark () in all sub-areas your agency is applying to serve in PSA 12: Sub-area 1 – 60626, 60640, 60645, 60659, 60660 Sub-area 2 – 60625, 60630, 60631, 60646, 60656 Sub-area 3 – 60634, 60635, 60639, 60641, 60666, 60707 Sub-area 4 – 60613, 60614, 60618, 60647, 60657 Sub-area 5 – 60601, 60602, 60603, 60604, 60605, 60606, 60607, 60610, 60611, 60622, 60661 Sub-area 6 – 60615, 60616, 60637, 60649, 60653 Sub.
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How to fill out the IL-402-1125 online
Filling out the IL-402-1125 form is an important step in applying for certification as a provider in the Community Care Program. This guide will provide you with clear, step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to successfully complete the IL-402-1125 online.
- Click ‘Get Form’ button to obtain the form and open it in your editor.
- Begin with Part A, Proposed Service Area. Check the sub-areas your agency plans to serve and provide specific details if your geographic area is smaller than a county. Remember to attach a map of the proposed area.
- Proceed to Part B, Applicant Information. Fill in the legal name of the agency, address of the administrative office, as well as contact details including a name, title, phone number, and email address for the contact person.
- Complete the business hours section and provide the hours of operation for your administrative office.
- If applicable, complete questions 5-11 for each local office associated with your agency. Provide the address and contact details for each local office, including the business hours and service hours.
- In Part C, Service Information, answer the questions by checking either 'Yes' or 'No' for each of the compliance statements regarding Community Care Program rules and responsibilities.
- Part D addresses Transportation. Indicate how transportation will be provided to participants and provide necessary details.
- In Part E, Electronic Visit Verification (EVV) Certification, fill out the contact person's information and specify the type of EVV system your agency will use. Confirm whether participants can electronically verify services delivered.
- Complete Part F if you are requesting approval to subcontract. Provide details for the requesting agency as well as the subcontractor.
- In Part G, complete the applicant's signature page, certifying that the information is accurate, and include notary information where required.
- Once all sections are complete, review the form for accuracy. You can save changes, download a copy, print it, or share the form as needed.
Take action and fill out the IL-402-1125 online to ensure your agency can provide essential services.
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What should I put on my withholding form?
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How to fill out Employee Withholding Certificate form?
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How to fill out an employee's withholding certificate?
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How to fill out form 1125 a?
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How do I write a check to the Illinois Department of Revenue?
When writing a check to the Illinois Department of Revenue, make sure to include your name, address, Social Security number, and the correct payment amount. It is important to make your check payable to the Illinois Department of Revenue. Additionally, write any necessary tax year and form number in the memo section for clarity. For guidance, you can always refer to IL-402-1125 to ensure accuracy.
Where to send Illinois tax payment?
Your Illinois tax payment should be sent to the address indicated on your tax form or notice. If you're uncertain, MyTax Illinois can provide guidance on where to send your payments. Be aware that different types of payments may have different addresses. You can also use IL-402-1125 for additional help in determining the right destination.
How do I request a letter ID on MyTax Illinois?
To request a letter ID on MyTax Illinois, you need to log in to your account. If you do not have an account, you can create one using your personal information. After logging in, navigate to the appropriate section where you can request your letter ID. For further details, refer to the IL-402-1125 resource for a smooth process.
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