Form 04FC004E (DCFS-118)



Child's name

      |Date of birth

      |KK number

      |Resource number

      | |Please identify the number of items the child has upon entry into and upon exiting your home and identify all purchases made while the child is placed in your home, including clothing, toys, other personal possessions, and valuables. When the child no longer has a particular item, please note the reason, such as when the child outgrows clothing.

|Items |Number |Number of purchases |Date(s) of |Number |

| |at entry | |purchases |at exit |

|Shoes |      |      |      |      |

|Socks |      |      |      |      |

|Underwear |      |      |      |      |

|Shirts/blouses |      |      |      |      |

|Pants/shorts |      |      |      |      |

|Skirts/dresses |      |      |      |      |

|Pajamas/gowns |      |      |      |      |

|Coats/jackets |      |      |      |      |

|Other, such as jewelry, Life Book, toiletries, furniture, games, toys, radio, television, and bicycle |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

| | | | |      |

|Foster parent signature | |Child Welfare (CW) worker signature | |Date of entry |

| | | | |      |

|Foster parent signature | |CW worker signature | |Date of exit |

|Comments:       |

Routing: Original - CW case record

Copy - foster parent

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