Form Icpc 100a - Interstate Compact On The Placement Of Children Request

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ICPC 100A

Please type

REV. 8/2001

INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN REQUEST

TO:

FROM:

SECTION I - IDENTIFYING DATA

Notice is given of intent to place - Name of Child:

Ethnicity: Hispanic Origin:

Yes

Unable to determine/unknown

Social Security Number:

ICWA Eligible

Race:

Yes

American Indian or

Native Hawaiian/ Other

Alaskan Native

Pacific Islander

Sex:

Date of Birth

Title IV-E determination

Asian

Black or African American

White

Yes

Pending

Name of Mother:

Name of Father:

Name of Agency or Person Responsible for Planning for Child:

Phone:

Address:

Name of Agency or Person Financially Responsible for Child:

Phone:

Address:

SECTION II - PLACEMENT INFORMATION

Name of Person(s) or Facility Child is to be placed with:

Soc Sec # (optional):

Address:

Phone:

Type of Care Requested:

Parent

ADOPTION

Relative (Not Parent)

IV-E Subsidy

Foster Family Home

Residential Treatment Center

Relationship: _______________

Non IV-E Subsidy

Group Home Care

Institutional Care-Article VI,

__________________________

To Be Finalized In:

Child Caring Institution

Adjudicated Delinquent

Other:

Sending State

Receiving State

__________________________

Current Legal Status of Child:

Protective Supervision

Sending Agency Custody/Guardianship

Parental Rights Terminated-Right to Place for Adoption

Parent Relative Custody/Guardianship

Unaccompanied Refugee Minor

Court Jurisdiction Only

Other:

SECTION III - SERVICES REQUESTED

Initial Report Requested (if applicable):

Supervisory Services Requested:

Supervisory Reports Requested:

Parent Home Study

Request Receiving State to Arrange Supervision

Quarterly

Relative Home Study

Another Agency Agreed to Supervise

Semi-Annually

Adoptive Home Study

Sending Agency to Supervise

Upon Request

Foster Home Study

Other:

Name and Address of Supervising Agency in Receiving State:

Enclosed:

Child's Social History

Court Order

Financial/Medical Plan

Other Enclosures

Home Study of Placement Resource

ICWA Enclosure

IV-E Eligibility Documentation

Signature of Sending Agency or Person:

Date:

Signature of Sending State Compact Administrator, Deputy or Alternate:

Date:

SECTION IV - ACTION BY RECEIVING STATE PURSUANT TO ARTICLE III(d) of ICPC

Placement shall not be made

Placement may be made

REMARKS:

Signature of Receiving State Compact Administrator, Deputy or Alternate:

Date:

DISTRIBUTION (Complete six (6) copies):

• Sending Agency retains a (1) copy and forwards completed original plus four (4) copies to:

• Sending Compact Administrator, DCA, or alternate retains a (1) copy and forwards completed original and three (3) copies to:

• Receiving Agency Compact Administrator, DCA, or alternate who indicates action (Section IV) and forwards a (1) copy to receiving agency and the completed original and one (1) copy to sending

Compact Administrator, DCA, or alternate within 30 days.

• Sending Compact Administrator, DCA, or alternate retains a completed copy and forwards the completed original to the sending agency.