Get Il Il-402-1127 2015-2026

Filling out the IL IL-402-1127 form is an essential step for agencies seeking provider certification in Illinois. This guide provides a clear, step-by-step approach to assist you in completing the form accurately and effectively, ensuring a smooth online submission process.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the document and open it for editing. This action provides access to the application needed for certification.
2. Begin with Part A: Applicant Information. Fill out the legal name of the applicant agency, including any doing business as (D/B/A) names, as well as a commonly used name if it differs from the legal name. Don't forget to include the website address.
3. Continue in Part A by providing the administrative office's address. Include the street address, city, state, zip code, and business hours; also designate a contact person at the administrative office with their phone number, fax number, and email.
4. In section 3 of Part A, input the name and position of the applicant's authorized representative. Include their contact information as well.
5. Move on to Part B: Organizational Information. Select and mark the legal structure type of the applicant agency, and ensure to attach appropriate documentation supporting this structure.
6. List the names and titles of the directors, officers, or owners of the applicant agency in Part B. If necessary, attach an additional page.
7. Proceed to Part C: Financial Information. Fill in your agency's fiscal year dates and the Illinois Department of Human Rights number, if applicable.
8. Provide either your Federal Employer Identification Number (FEIN) or Social Security Number (SSN), based on the agency type, and attach a completed W-9 form.
9. Continue with required financial attachments. These include an audited financial report, agency business plan, bank references, and a budget narrative discussing financial monitoring and potential cash flow issues.
10. In Part D: Computer Capabilities, indicate whether your agency's computer system meets the minimum specifications for applications.
11. Address business practice history in Part E. Mark any applicable issues that pertain to past business practices and attach relevant documentation for any checked items.
12. List references in Part E, ensuring to have at least five non-relative individuals or businesses who can verify your agency's qualifications.
13. In Part F: Service Information, mark the type of services your agency is seeking certification for and detail your agency's experience, providing any required supporting documents.
14. Prepare Part G, requiring attachments related to personnel policies and procedures.
15. Complete Part H: Applicant Certifications, where you will verify the accuracy of your information before signing and dating the document.
16. Finally, prepare to submit the form by returning the original and two copies to the Illinois Department on Aging. Remember to keep a copy for your records.

Start completing your IL IL-402-1127 form online today to ensure your agency is certified and ready to provide essential services.