SFN 966, (ICPC 100-B), Interstate compact Report on the Placement/Replacement Status of Child 619-01-30-05

(Revised 4/18/01 ML #2678)

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SFN 966

 

PURPOSE: To confirm that a placement in accordance with the Compact has been made, to indicate changes in placement, and to confirm the termination of the placement.

 

NUMBER OF COPIES AND DISPOSITION: Complete separate form for each child involved.

  1. The sending agency retains one copy and forwards three copies to:
  2. The State Compact Administrator who retains one copy and forwards two copies to:
  3. The receiving Compact Administrator who retains one copy and forwards one copy to the respective agency.

 

INSTRUCTIONS FOR COMPLETION: In the first two blocks, enter the name and address of the ICPC Administrator whose state is submitting the reported information (FROM) and the name and address of the ICPC Administrator to whom the form is being forwarded (TO). If the information is not available to you, this may be left blank to be completed in the state office by the deputy compact administrator.

 

 

Section 1: Identifying Information

 

Enter the full legal name and birthdate of the child concerning whom this placement information is being reported.

 

 

Section 2: Placement Status

If you have submitted SFN 965, 100A, to request placement approval and have decided not to explore that resource further, mark the box for Placement Request Withdrawn and the date of your decision.  This item will be used only when no action has yet been taken on SFN 965, 100A. If you are withdrawing more than one request, submit separate ICPC 100-Bs on each and list each respective Placement Resource in that space under IDENTIFYING INFORMATION.

 

To confirm the Initial Placement, mark the next box and indicate the resource’s name and address and the exact date of placement.  For Type of Care, enter the some information that is marked for that item on SFN 965, 100A: Foster Family Care, Adoption, etc., with relative placements, specify the relationship.

 

If some aspect of the placement changes while the child remains in the receiving state, mark the Placement Change box and indicate the exact date of the change; i.e. mother remarries and/or moves to a new address, a termination of parental rights has occurred so the placement type changes from foster care to adoption. If the child remains in the receiving state and the level of care changes, it is possible that a new SFN 965,100A, could be required. Contact the deputy compact administrator at the state office for directions.

 

 

Section 3: Compact Termination

 

Adoption Finalization: If an ICPC adoptive placement has been finalized, mark the box and the appropriate box for the state in which finalization occurred, Sending or Receiving.  

 

Child Reached Age Majority/Legally Emancipated: (Age of majority in sending state.)  Mark this box if the child has reached age 18 and has simultaneously ceased to be the responsibility of the sending agency or if the child has become emancipated through such legal action as marriage or court decision.

 

Legal Custody and/or Guardianship Awarded or Returned to: This item is to be marked when final custody or guardianship (wording varies among states) has been disposed of with the concurrence of the receiving state.  Indicate the Name and Relationship of the person(s) to whom this applies.

 

Treatment Completed: Mark this item when the placement resource has been providing a specific treatment-oriented service, that service has been completed and the child is, therefore, being discharged from the facility (e.g. Residential Treatment Center).

 

Sending State’s Jurisdiction Terminated: This item is marked when the jurisdiction of the sending state has ended for some reason other than that which relates to the third category (Legal Custody . . .); for example, if formal legal custody/guardianship is not going to be addressed but both states agree that supervision is no longer required or if both states agree to transfer jurisdiction to the receiving state. If the sending state’s jurisdiction is terminated without the concurrence of the receiving state (including custody/guardianship transfer), the decision was made unilaterally and that box should be marked as well.

 

Child Returned to Sending State: If the child was returned to the sending state (placement disrupted or was intended to be temporary), mark this box.

 

Approved Resource Will Not Be Used for Placement: This box should be marked when you have received an approved ICPC-100A (SFN 965) but have decided not to place the child with that resource.

 

Other: Please mark and specify if the reason for Compact Termination is not listed above; for example, the child ran away and his/her whereabouts are unknown, etc.

 

Date of Termination: Indicate the exact date of the activity which terminated the Compact Agreement.

 

 

Section 4: Signatures

 

If a private individual or local agency is completing the form, please have a designated person sign the first block, identify his/her agency, and date the signature.

 

 

Section 5: Distribution

 

Self-explanatory.