Ill. Admin. Code tit. 89, pt. 411, subpt. I, app C
AGREEMENT FOR THE VOLUNTARY SURRENDER OF A LICENSE
(Investigations pending)
I, (name of head of the governing body), affirm that the governing body of the (name of the secure child care facility) met on (date of meeting) and agreed to voluntarily surrender license number __________ , with an expiration date of __________ (original license attached to this agreement).
I further state that the secure child care facility has reason to believe that it is presently under investigation by the Department of Children and Family Services for a licensing complaint or a report of suspected abuse or neglect, by the DCFS Office of the Inspector General or by any local, State or federal law enforcement agency for any reason, or that litigation is pending between the Department and the secure child care facility.
In the following space, identify the investigating agency and summarize the basis of the investigation, if known. Attach additional pages, if necessary.
In the following space identify all pending litigation between the Department and the secure child care facility. Provide the name of the case, docket number, and:
a) the county in which it is filed, if a State action;
b) appellate district, if on appeal;
c) the district, if it is a federal action; or
d) the circuit, if it is on appeal.
I further state that the governing body of the secure child care facility or its successor will not apply for a license as a secure child care facility until (insert date at least one year from today's date).
__________________________________ | ||||
Printed name and title of head of governing body | ||||
__________________________________ | ||||
Signature/Date | ||||
County of | ) | ss | ||
) | ||||
State of Illinois | ) | |||
Subscribed and sworn before me on) | _________________________________ | |||
(date) | ||||
_________________________________ | ||||
Notary Public | ||||
ACCEPTANCE OF VOLUNTARY SURRENDER BY A LICENSING ADMINISTRATOR
I, (name of the licensing administrator), accept the voluntary surrender of the license and agree that the Department will not seek to revoke the license and will not refuse to renew the license if the statements made above are correct and complete. As part of this agreement, the Department will not accept another application for license as a secure child care facility before (insert date at least one year after the date of acceptance of the voluntary surrender).
_____________________________________
Printed name and title of head of governing body
_____________________________________
Signature of DCFS licensing administrator/Date
Ill. Admin. Code tit. 89, pt. 411, subpt. I, app C