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Get ICPC 100A 2019-2024

One form per child Please type ICPC 100A REV. 8/2001 INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN REQUEST FROM TO Notice is given of intent to place - Name of Child Social Security Number Sex Date of Birth SECTION I - IDENTIFYING DATA Ethnicity Hispanic Origin ICWA Eligible Yes No Unable to determine/unknown Race American Indian or Alaskan Native Asian Title IV-E determination Pending Name of Mother Native Hawaiian/ Other Pacific Islander Black or African American White Name of Agency or Person Responsible for Planning for Child Phone Address SECTION II - PLACEMENT INFORMATION Name of Person s or Facility Child is to be placed with Type of Care Requested Foster Family Home Group Home Care Child Caring Institution Residential Treatment Center Institutional Care-Article VI Adjudicated Delinquent Soc Sec optional Parent Relative Not Parent Relationship Other ADOPTION IV-E Subsidy To Be Finalized In Sending State Receiving State Current Legal Status of Child Sending Agency Custody/Guardianship Parent Relative Custody/Guardianship Court Jurisdiction Only Protective Supervision Parental Rights Terminated-Right to Place for Adoption Unaccompanied Refugee Minor 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 Upon Request Foster Home Study Name and Address of Supervising Agency in Receiving State Enclosed Child s Social History Home Study of Placement Resource Court Order ICWA Enclosure Financial/Medical Plan IV-E Eligibility Documentation Signature of Sending Agency or Person Date Other Enclosures 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 DISTRIBUTION Complete six 6 copies 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.

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