DHS-4332, interstate compact placement request

Michigan Department of Health and Human Services (MDHHS)

Interstate Compact on the Placement of Children (ICPC) – 100A

(Revised 10-23)

section 1 – identifying data

Name of child	Ethnicity - Hispanic Yes No Unable to determine/unknown

Social Security Number	Indian Child Welfare Act (ICWA) Eligible Yes No	Tribe

Race

American Indian or Alaskan Native Asian White	Native Hawaiian or Other Pacific Islander Black or African American

Sex	Gender	Date of Birth

Title IV-E Eligible Yes No Pending

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 2 – placement information

Types of Care Requested Adoptive Home Public Private Subsidy IV-E Non-IV-E Pending None Finalizing In Sending State Receiving State Foster Family Home Group Home Care Child Care Institution Residential Treatment Center Parent Institutional Care – Article VI Adjudicated Delinquent Relative (Not Parent) Relationship Other	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 Other

Name of Person(s) or Facility Child is to be placed with	Social Security Number (optional)

Phone Number	Social Security Number (optional)

Address

Private/Independent Adoptions Only – Complete if different from above.

Name(s) of Prospective Adoptive Resource	Social Security Number (optional)

Phone Number	Social Security Number (optional)

Address

section 3 – services requested

Initial Report Requested (if applicable) Adoptive Home Study Foster Home Study Parent Home Study Relative Home Study

Supervisory Services Requested

Request Receiving State to Arrange Supervision Sending Agency to Supervise	Another Agency to Supervise Other

Supervisory Reports Requested Quarterly Monthly Other

Name of Agency Contracted to Provide Supervision in Receiving State (If applicable)

Address of Agency Contracted to Provide Supervision in Receiving State (If applicable)

Signature of Sending Agency or Person	Date

Signature of Sending State Compact Administrator, Deputy or Alternate	Date

section 4 – 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

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.
AUTHORITY: Public Act 114, 1984. COMPLETION: Required. PENALTY: Sending/Receiving Agency could lose their license.

INSTRUCTIONS FOR COMPLETING FORM ICPC-100A INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN REQUEST

Form ICPC-100A is the sending agency’s formal written notice to the receiving state of its intention to make an interstate placement and a request for a finding as to whether the placement would or would not be contrary to the interests of the child. With most placements, it is also a formal request for a home study. Following review by the receiving state, it is the official notification that the proposed placement may or may not be made. A favorable finding means that the placement can be made in conformity with the Compact. An unfavorable finding means that the placement would be unlawful. The actual making of the placement bring into operation a number of rights and obligations set forth in the Compact, primarily those contained in Article V, Retention of Jurisdiction.

Form ICPC-100A must accompany all requests for placement to which the Compact is applicable and it should be favorably acted upon by the receiving state before any Compact placement is made.

SPECIFIC INSTRUCTIONS

In the first two blocks, enter the name and state of the ICPC Administrator (or Deputy) whose state is submitting the request (FROM) and the name and state of the ICPC Administrator (or Deputy) to whom the request is being forwarded (TO). If the sending or receiving state is a decentralized state (i.e.: CA, OH, or CO), please provide the county agency as applicable.

Section 1 – IDENTIFYING DATA

Fill out one form per child to be placed. Enter the full legal name, Social Security Number, ICWA (Indian Child Welfare Act) eligibility*, Title IV-E eligible, sex, (defined as the anatomy of the child), gender (defined as what the child identifies such as male, female, transgender, etc.), date of birth, and ethnic group of the child for whom this placement is proposed. If the child is known by a nickname, place it in parenthesis beside the legal name.

Enter the names of the legal parents. In most instances, the legal parents 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 parental rights have been voluntarily relinquished or 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, telephone number, and email addresses 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 (the sending agency). *Email addresses are optional.

* An “Indian Child” means any unmarried person who is under age eighteen and is either (a) a member of an Indian tribe or (b) is eligible for membership in an Indian tribe and is the biological child of a member of an Indian tribe.

Section 2 – PLACEMENT INFORMATION

* Required: Enter the full name, address, and telephone number of the person(s) or facility with whom the sending agency proposes to place the child. Optional: Social security number(s).

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

Adoptive Home: 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. If this is a request for private or independent adoption, you are required to also complete the fields for the names, address, social security numbers and telephone numbers for the prospective adoptive resource. Indicate if it is a federally funded adoption subsidy (IV-E) or a state or local funded subsidy (Non IV-E), pending (if not yet determined), or none; mark in which state the adoption is to be finalized (sending or receiving) or pending if not yet determined.

Adoption: mark the specific/appropriate type of adoption; identify whether the adoption is public and processed via a public child welfare agency or private and processed utilizing the services of a private or independent adoption agency or representative.

Subsidy: mark one for public adoptions to denote IV-E federal, Non-IV-E state or local, or None no financial support. Select Pending if not yet determined.

Finalizing In: mark one to indicate the state in which the adoption will be finalized if known, otherwise mark Pending.

Name(s) of Prospective Adoptive Resource: provide the name, address, social security number and telephone number of the individual(s) who will be adopting this child and with whom the child will be residing, if it differs from the section immediately above (Name of Person(s) or Facility Child is to be placed with).

Foster Family Home: a foster family home is a facility providing care and guidance for a child or children not related to the caretaker for regular 24-hour care, or a certified kinship care home. A family foster home may not operate without a license or a certificate as required by the laws of the receiving State.

Group Home Care: a resource which is licensed or approved 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.

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

Residential Treatment Center: a group care facility which provides a specific treatment program outside the realm of a medical hospital, psychiatric hospital or institution for the mentally retarded or mentally ill; e.g., a residential program for the treatment of alcohol/drug abuse. The receiving state is not obligated to supervise this type of placement made by the sending state.

Parent(s): a biological, adoptive parent or legal guardian as determined by applicable state law and is responsible for the care, custody and control of a child or upon whom there is legal duty for such care.

Institutional Care (Article VI), Adjudicated Delinquent: a group care facility for adjudicated delinquent whose proposed placement is according to Article VI of the ICPC. These facilities may include group homes and residential treatment centers and may serve non-delinquents as well.

Relative (not parent): specify relationship, such as a birth or adoptive brother, sister, stepparent, stepbrother, stepsister, uncle, aunt, first cousin, niece, nephew, as well as relatives of half-blood or marriage and those denoted by the prefixes of grand and great, including grandparent or great grandparent, or as defined in state statute for the purpose of foster and or adoptive placements.

Other: specify a type of care not already listed; e.g., Non-relative Free Home (an unrelated family which does not require foster home licensure in the receiving state and does not need or want foster care payments), Independent Living Arrangement (an older teenager who is still under the jurisdiction of an agency or court but is capable of independent living without the supervision of a foster home or group home), Maternity Home, or Extended Foster Care (defined as youth aged 18-21 years old).

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 a public agency. For example: a public agency may be social services, youth corrections, probation/parole, or a tribe. The sending agency may also be a licensed private child placement agency, an adoption agency, or a birthmother if allowed by state law.

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.

Court Jurisdiction Only: the sending court has an open abuse, neglect or dependency case that establishes court jurisdiction with the authority to supervise and/or remove and place the child for whom the court has not taken guardianship or legal custody. For further reference, see Regulation 3, paragraph C under section 2. *Note: Domestic cases are not ICPC.

Protective Supervision: a legal status created by court order under which the child is permitted to remain in the child’s home or is placed with a relative or other suitable person and the court, the department of human services or another agency designated by the court provides supervision and assistance.

Parental Rights Terminated-Right to Place for Adoption: the sending agency has accepted a voluntary relinquishment of parent rights and/or has completed court action terminating parental 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 the initial placement into the United States but to request 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 Minor 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 3 – SERVICES REQUESTED

Initial Report Requested: 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 of the type of care indicated in Section II.

Supervisory Services Requested: 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 placements 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 (which may or may not include licensure) to provide services in its state.

Other: mark this box if requesting supervision for Extended Foster Care youth (defined as youth aged 18-21 years).

Supervisory Reports Requested: to be completed even though placement may not be a certainty at this time. Indicate how frequently you wish to receive progress reports; the standard timeframe is Semi-Annually; Quarterly (see Regulation 11, section 7); Monthly; or Other when you wish to receive reports in a timeframe not noted above.

Name and Address of Supervising Agency in Receiving State: 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.

Enclosed:

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 Resource: attach a current home study if one is not being requested; most likely to be marked if you already have an approved home study or the child is re-locating with a placement resource) and the home study is enclosed (e.g. private adoptions, foster care, parent placements).

Court Order: all applicable court documents should be enclosed; e.g., custody/guardianship orders, surrenders, orders terminating parental rights, and orders requesting a home study for the court. ICWA Enclosure: obtain a letter from the child’s Tribe showing that the child is a member or is eligible for membership.

Financial/Medical Plan: attach the plan of how the proposed placement will be funded and how the child/children’s medical needs will be covered.

IV-E Eligibility Documentation: attach a copy of the determination of IV-E eligibility.

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

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).

Signature of Sending State Compact Administrator, Deputy or Alternate: the ICPC-100A must be signed and dated by the Compact Administrator, Deputy or alternate in the sending state, if the regulations of the sending state provide for transmittal of the ICPC-100A through the sending State’s Compact Office. This is almost always the case.

Section 4 – ACTION BY RECEIVING STATE PURSUANT TO ARTICLE III (d) of ICPC

This section is completed by the Compact Administrator, Deputy, or alternate 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, provisional approval, or that an affirmative notice under Article III (d) is being given retroactively. The Compact Administrator, Deputy, or alternate then signs and dates the form.

DISTRIBUTION:

Complete six (6) copies and distribute as follows (unless the form is submitted electronically or through

NEICE):

Sending Agency retains a (1) copy and forwards the completed 100A original plus four (4) copies to:

Sending Compact Administrator, DCA, or alternate retains a (1) copy and forwards the completed 100A original plus 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 100A original and one (1) copy to sending Compact Administrator, DCA, or alternate within 30 days.

Sending Compact Administrator, DCA, or alternate retains a (1) completed copy and forwards the completed original to the sending agency.