B Acceptance of Voluntary Surrender of License – No Investigations Pending

Section 411.APPENDIX B   Acceptance of Voluntary Surrender of License – No Investigations Pending OFFER OF VOLUNTARY SURRENDER BY A SECURE CHILD CARE FACILITY (No investigations pending) I, (Name of head of governing body), affirm that the governing body of the (name of the secure child care facility) met on (date of meeting) and voluntarily agreed to surrender license number __________, expiration date of __________ (original license attached to this agreement). I further state that the facility, to the best of the knowledge of myself and each member of the governing body, is not presently under investigation by the Department of Children and Family Services for any licensing complaint or report of suspected abuse or neglect or by the DCFS Office of Inspector General or by any other state agency of any state or its inspector general or by any local, State or federal law enforcement agency for any reason. I acknowledge that if, at any time after the acceptance of the offered surrender of license, the Department learns that the secure child care facility knew or should have known that it was under investigation at the time it offered to surrender its license and failed to disclose the information to the Department, the Department at its option may set aside its acceptance of the surrender and proceed to take appropriate action against the licensee and the license, including, but not limited to, the revocation of the license or the refusal to renew the license. 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 REPRESENTATIVE (No investigations pending) I, (name of licensing administrator), accept the voluntary surrender of this license and affirm that, to the best of my knowledge, this secure child care facility is not presently under investigation by the Department of Children and Family Services for any licensing complaint or report of suspected abuse or neglect, and that neither the DCFS Office of the Inspector General nor any other state agency of any state or its office of inspector general nor any local, any State or any federal law enforcement agency has given the Department notice that this secure child care facility is under investigation. Further, no litigation exists between the Department and this facility. Printed name and title of head of governing body Signature of DCFS licensing administrator/Date