Forms Appendix 619-01-30

 

SFN 965 (ICPC 100A), Interstate Compact Application Request to Place Child 619-01-30-01

(Revised 5/1/12 ML #3329)

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SFN 965

 

PURPOSE: This form is initiated by the sending agency to request approval to place a child in another state.  It provides relevant information regarding the placement.

 

INSTRUCTIONS: Indicate if child is IV-E eligible.  In the first two blocks, enter the name of the sending and receiving state.

 

 

Section I. Identifying Information

 

Enter the full legal name, sex, race/ethnicity, ICWA eligibility, and birthdate of the child for whom this placement is proposed. Enter the names of the legal mother and legal father. In most instances, the legal mother and legal father will be the birth parents. In cases where an adoption has been finalized, the adoptive parents will be the legal parents. If the parent(s) is deceased, enter “deceased” after the parent’s name. If parent rights have been voluntarily relinquished terminated by the court, indicate in parenthesis beside the name; if you prefer in that instance to withhold the name, simply enter the status of the parent’s rights.

 

Enter the complete name, address, and telephone number of the agency or person who is responsible for planning for the child and who is financially responsible for the child. In most instances, these two items will be the same (sending agency).

 

 

Section II.  Placement Information

 

Enter the full name, address, and telephone number of the person(s) or facility with whom the sending agency proposes to place the child. If the resource, e.g., foster family care, is yet to be determined, leave these items blank.

 

Place an X in the box which designates one of the following Types of Care:

 

Family Foster Care: A substitute family resource which is or is intended to be licensed as a foster home and which will be entitled to foster care payments.

 

Group Home Care: A resource which is licensed as a group home and which provides substitute care for a fee; usually a modified family-type setting which serves more children than a foster home but fewer than an institution.

 

Residential Treatment Center: A group facility which provides a specific treatment program outside the realm of a medical hospital, psychiatric hospital or institution for the mentally retarded; e.g., a residential program for the treatment of alcohol/drug abuse.

 

Child-Caring Institution: A group care facility which is licensed to provide custodial care to a larger number of children than a group home.

 

Institutional Care (Article VI): A group care facility which serves only delinquent children and which is being proposed as a resource under the specification of article VI of the ICPC.

 

Parent(s): Legal parent(s).

 

Relative (not parent): Specify relationship such as maternal aunt, paternal grandparents, brother, etc.

 

Other: Specify a type of care not already listed, e.g. maternity home.

 

Adoption: Refers to both agency and private/independent adoptive placement prior to finalization; this may refer to an initial placement with a family where adoption is the intention, or it may refer to the movement of an adoptive family from State A to State B following placement.  Indicate if an adoption subsidy or adoption assistance (Title IV-E) is applicable, and mark in which state the adoption is to be finalized.

 

Place an X in the box which designates one of the following kinds of Legal Status:

 

Sending Agency Custody/Guardianship: Child is in the full legal custody or guardianship (depending on the terminology of the state) of the public social service agency or a licensed private child-placing agency.

 

Parent/Relative Custody/Guardianship: Child is not under the jurisdiction of either an agency or the court but is the full legal responsibility of parent or relative; most likely to be marked when a family wishes to place a child in one of the group care facilities listed above.

 

Court Jurisdiction Only: Child is not the legal responsibility of an agency; the court has full responsibility for weighing the requested information and making the placement decision and is, therefore, the sending agency; most likely to be marked when two or more relatives have taken a dispute over custody into court and at least one of the disputing relatives is not a parent.

 

Parental Rights Terminated-Right to Place for Adoption: Sending agency has accepted a voluntary relinquishment of parental rights and/or has completed court action terminating rights and now holds complete jurisdiction over the child with the right to place for adoption.

 

Unaccompanied Refugee Minor: This form is not used to report placement and services in a second state after a U.S. agency or court has been granted full legal responsibility (custody/guardianship). Mark this block only if that is the case; also mark the Sending Agency Custody/Guardianship block. If this is an Unaccompanied Refugee Minot whose status warrants the ICPC-100A's specific to those children (not the legal responsibility of a U.S. agency or court), do not use this form.

 

Other: Legal status is not otherwise listed; e.g. legal action, such as a petition for custody/guardianship or to terminate parental rights, is pending; e.g. the child is the responsibility of the sending agency under a Voluntary Agreement with the parent or legally responsible relative and no court action has been taken or is pending to alter that family member’s legal rights over the child.

 

 

Section III.  Services Requested

 

Initial Report: If the proposed placement is not for a group care placement and a current home study has not yet been received, mark the box for the appropriate type of home study needed based on the type of care indicated in Section II.

 

Supervisory Services: Place an X in one of the following boxes to indicate how Supervisory Services are to be conducted.

 

Request Receiving State to Arrange Supervision: Mark this box if the sending agency cannot supervise and does not have a contractual or other agreement with a pre-determined agency to provide these services; it is usually the public social service agency which will be asked to provide supervision following an approved home study and subsequent placement.

 

Another Agency Agreed to Supervise: Mark this box if the sending agency already has received the formal agreement of a pre-determined supervisory agency; most likely to be marked in agency adoptive placement where an agency in the receiving state already has provided an adoptive home study and will be providing ongoing services to the adoptive family. Do not mark this item simply because you know which county office of the public agency will receive this referral and might even have discussed the case over the telephone; that does not constitute an agreement to supervise.

 

Sending Agency to Supervise: Mark this box if it is logistically feasible, it is the best case plan, and the receiving state has granted the sending agency permission to provide services in its state.

 

Supervisory Reports: To be completed even though placement may not be a certainty at this point. Indicate how frequently you wish to receive progress reports; most common is quarterly. Be very discriminating in your use of Upon Request because it leaves the provision of supervision open-ended with no commitment to provide that service until you request it; use Other when you wish to receive reports in a less usual time frame, such as monthly or annually (specify the time frame).

 

If you know the name and address of the supervising agency, type that information onto the line so indicated. If not known by the sending agency, that information should be completed by the receiving state’s compact office following receipt of a recommendation indicating that placement may be made.

 

Indicate which items are Enclosed:  

 

Child's Social History: Should accompany the majority of referrals; includes the pre-placement summary on adoption referrals and can be written with non-identifying information, if appropriate and preferred.

 

Home Study of Placement Resources: Attach a current home study if one is not being requested; most likely to be marked if you already have an approved adoptive home study or the child is re-locating with foster parents and the foster home study is enclosed.

 

Court Order: All applicable court documents should be enclosed; e.g., custody-guardianship orders, surrenders, orders terminating parental rights, and orders granting care, custody, and control to the public agency.

 

Financial/Medical Plan: SFN 395, includes Title IV-E eligibility verification.

 

Other Enclosures: Indicates other pertinent materials, such as psychological evaluations, permanency plan, medical reports, and school reports; it is not necessary to itemize them on the form.

 

ICWA Enclosure: Include statement regarding ICWA eligibility.

 

Signature of Sending Agency or Person: The form should be signed and dated by anyone outside of the Compact Office who is completing the form; includes a person with this authority in the county social services agency, private agency or court, and any private individual or family member who is legally responsible for the child (as indicated in Section I and Section II, Legal Status, above).

 

The ICPC-100A, SFN 965, must be signed and dated by the Compact Administrator or alternate in the Sending State.

 

 

Section IV.  Action by Receiving State

 

This section is completed in the Compact Office in the Receiving State.  The designated person reviews the proposed placement and all required information and indicates whether the placement can or cannot lawfully be made.  Remarks might include conditions or reservations to be noted or that an affirmative notice under Article III(d) is being given retroactively.  The Compact Administrator or alternate then signs and dates the form.

 

Distribution: Self-explanatory.