Icpc 100A Form PDF Details

In the landscape of child welfare and the intricate legal frameworks that guide the placement of children across state lines, the Interstate Compact on the Placement of Children Request form, commonly known as the ICPC 100A, occupies a critical role. This meticulously crafted document, last revised in May 2019 and effective from January 2020, serves as a crucial vehicle for communication and agreement between states. It ensures the safe, suitable, and legal transference of care for children whose placement needs cross state jurisdictions. As a single-form document dedicated to each child, it encompasses a broad spectrum of vital information, ranging from the identification data of the child in question—spanning ethnicity, potential disability, social security number, and eligibility for federal assistance under Title IV-E and the Indian Child Welfare Act (ICWA)—to intricate details about the proposed placement. The form details the types of care requested, current legal status of the child, any subsidies in play, and importantly, the legal and financial responsibilities of the involved agencies or persons. Beyond just the logistic and legalistic facets, the form extends into a commitment to ongoing support and oversight post-placement, requesting details on the supervisory services and follow-up reports that will ensure the child's continued welfare. Through its comprehensive structuring, the ICPC 100A form embodies the intersection of legal obligation, child welfare considerations, and interstate cooperation, making it a cornerstone document in the field of child placement across state lines.

QuestionAnswer
Form NameIcpc 100A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesicpc form 100 b, icpc compact placement children request, icpc 100 a, icpc 100a placement request

Form Preview Example

ICPC 100A

 

 

 

 

 

 

One form per child; please type

 

 

REV. 05/2019; EFF. 01/2020

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

Unable to determine/unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number:

ICWA Eligible

Title IV-E Eligible

 

Race:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes No

Yes No Pending

 

American Indian or

Native Hawaiian/Other

 

 

 

 

 

 

Alaska Native

Pacific Islander

 

 

Sex:

Gender:

Date of Birth:

 

Asian

 

 

Black or African American

 

 

 

 

 

 

 

 

 

White

 

 

 

 

 

 

 

 

 

 

 

Name of Parent 1:

 

 

 

Name of Parent 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Agency or Person Responsible for Planning for Child:

Phone:

Address:

Email Address (optional):

Name of Agency or Person Financially Responsible for Child:

Phone:

Address:

Email Address (optional):

 

 

 

 

 

SECTION II—PLACEMENT INFORMATION

 

 

 

 

Types of Care Requested:

 

 

 

 

 

 

 

Current Legal Status of Child:

 

Public Placement

Private Placement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subsidy: IV-E

Non IV-E

Pending

None

 

 

 

 

 

Sending Agency Custody/Guardianship

 

Adoptive Home: Finalizing in:

Sending State

Receiving State

Pending

 

Parent Relative Custody/Guardianship

 

Foster Family Home

 

 

 

 

 

 

 

 

Court Jurisdiction Only

 

 

 

 

Group Home Care

 

 

 

 

 

 

 

 

Protective Supervision

 

 

 

 

Child-Caring Institution

 

 

 

 

 

 

 

Parental Rights Terminated—Right to Place for Adoption

 

Residential Treatment Center

 

 

 

 

 

 

 

Unaccompanied Refugee Minor

 

Parent

 

 

 

 

 

 

 

 

Other:

 

 

 

 

Institutional Care—Article VI Adjudicated Delinquent

 

 

 

 

 

 

 

 

 

 

 

 

 

Relative (Not Parent) Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

Soc. Sec # (optional):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soc. Sec # (optional):

Address:

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

If placement is with an agency (e.g., adoption, public, etc.) other than a residential treatment facility (RTF), please

 

 

 

 

identify the foster or adoptive resource where the child will reside.

 

 

 

 

 

 

 

 

 

 

*Name(s) of Prospective Adoptive or Foster Resource:

 

 

 

 

 

 

 

 

 

Soc. Sec # (optional):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soc. Sec # (optional):

Address:

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III—SERVICES REQUESTED

 

 

 

 

Initial Report Requested (if applicable):

Supervisory Services Requested:

 

 

 

 

Supervisory Reports Requested:

 

Adoptive Home Study

 

 

Request Receiving State to Arrange Supervision

 

Semi-Annually

 

Foster Home Study

 

 

 

Another Agency Agreed to Supervise

 

Quarterly

 

Parent Study

 

 

 

Sending Agency to Supervise

 

 

 

 

Monthly

 

Relative Home Study

 

 

Other

 

 

 

 

 

 

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 may be made

 

Placement shall not be made

 

Remarks:

 

 

 

 

 

 

 

 

 

Signature of Receiving State Compact Administrator, Deputy or Alternate:

 

Date

 

 

 

 

 

 

 

DISTRIBUTION: SEE 100A INSTRUCTIONS

How to Edit Icpc 100A Form Online for Free

Using the online tool for PDF editing by FormsPal, you are able to complete or alter 100a placement request here and now. We at FormsPal are dedicated to providing you the best possible experience with our editor by regularly adding new features and enhancements. With these updates, using our editor gets better than ever! All it requires is several easy steps:

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Step 2: With our handy PDF tool, you may do more than merely fill out forms. Express yourself and make your forms appear perfect with customized textual content incorporated, or tweak the file's original content to perfection - all that comes with an ability to incorporate your own photos and sign the PDF off.

It is actually straightforward to finish the document with this practical guide! Here is what you want to do:

1. It is advisable to fill out the 100a placement request correctly, thus be attentive when filling out the areas comprising all of these blank fields:

Completing part 1 of icpc 100 a

2. After filling in the last part, go on to the next step and enter the necessary details in all these fields - Group Home Care, ChildCaring Institution, Residential Treatment Center, Parent, Institutional CareArticle VI, Relative Not Parent Relationship, Other, Name of Persons or Facility Child, Protective Supervision, Parental Rights TerminatedRight to, Unaccompanied Refugee Minor, Other, Soc Sec optional Soc Sec, Soc Sec optional Soc Sec, and If placement is with an agency eg.

Writing segment 2 of icpc 100 a

Be really attentive when filling out Name of Persons or Facility Child and Parental Rights TerminatedRight to, since this is the part where many people make mistakes.

3. This 3rd section should also be fairly uncomplicated, Signature of Sending Agency or, Date, Date, Signature of Sending State Compact, Placement may be made, Remarks, SECTION IVACTION BY RECEIVING, Placement shall not be made, Signature of Receiving State, DISTRIBUTION See A Instructions, and Date - all these fields needs to be filled in here.

Date, Date, and Signature of Receiving State of icpc 100 a

Step 3: Soon after rereading the form fields, hit "Done" and you are all set! Sign up with FormsPal today and easily access 100a placement request, set for download. Every single modification you make is conveniently saved , so that you can customize the document at a later stage when necessary. FormsPal is dedicated to the personal privacy of our users; we make sure all personal information handled by our system is confidential.

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