Form Icpc 100b - Interstate Compact On The Placement Of Children Report On Child'S Placement Status

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ICPC 100B
One form per child
REV. 8/2001
Please type
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
REPORT ON CHILD'S PLACEMENT STATUS
TO:
FROM:
Child's Name:
Birthdate:
Mother's Name:
Father's Name:
SECTION II - PLACEMENT STATUS
Initial Placement of Child in Receiving State
Date Child Placed in Receiving State:
Name of Resource:
Address:
Type of Care:
Placement Change
Effective Date of Change:
Name of Resource:
Address:
Type of Care:
SECTION III – COMPACT PLACEMENT TERMINATION
Adoption Finalized
In Sending State
In Receiving State
Court Order Attached
Child Reached Majority/Legally Emancipated
Legal Custody Returned to Parent(s)
Court Order Attached
Legal Custody Given to Relative
Court Order Attached
Name:
Relationship:
Treatment Completed
Sending State's Jurisdiction Terminated with the Concurrence of the Receiving State
Unilateral Termination
Child Returned to Sending State
Child Has Moved to Another State
Proposed Placement Request Withdrawn
Name of Placement Resource:
Approved Resource Will Not Be Used for Placement
Name of Placement:
Other (Specify):
Date of Termination:
SECTION IV - SIGNATURES
Person/Agency Supplying Information:
Date:
Compact Administrator, Deputy or Alternate:
Date:
DISTRIBUTION (Complete four (4) copies of this form):
• Sending Agency retains a (1) copy and forwards completed original plus three (3) copies to:
• Sending Compact Administrator, DCA, or alternate retains one (1) copy and forwards two (2) copies to:
• Receiving Agency Compact Administrator, DCA, or alternate retains one (1) copy and forwards one (1) copy to the receiving agency

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