ࡱ> }|E@ ,[bjbj "v->>>RR-2Bo { .-0-0-0-0-0-0-/Ro10-u>!'i@!'!'0--'''!':R>.-'!'.-''-(*">*6 dm^['*+-0-*,1q'1*RR1>* !r"'#$P!!!0-0-RRq'RRINTERSTATE COMPACT PLACEMENT REQUEST TO:  FORMTEXT      FROM: VERMONT ICPC ICPC 100A PLEASE TYPE SECTION I  IDENTIFYING DATANotice is Given of Intent to Place: Name of Child:  FORMTEXT       SS #:  FORMTEXT       Sex:  FORMTEXT      Date of Birth:  FORMTEXT      Ethnic Group:  FORMDROPDOWN  Title IV-E  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  PendingName of Mother:  FORMTEXT      Name of Father:  FORMTEXT      Name of Agency or Person Responsible for Planning for Child:  FORMTEXT      Phone:  FORMTEXT      Address:  FORMTEXT      Name of Agency or Person Financially Responsible for Child:  FORMTEXT      Phone:  FORMTEXT      Address:  FORMTEXT      SECTION II  PLACEMENT INFORMATIONName of Person(s) or Facility Child is to be placed with:  FORMTEXT      Phone:  FORMTEXT      Address:  FORMTEXT      Type of Care:  FORMCHECKBOX  Institutional Care Article VI, adjudicated delinquent  FORMCHECKBOX  Parent  FORMCHECKBOX  Foster Home  FORMCHECKBOX  Relative  FORMCHECKBOX  Residential Treatment Center Relationship:  FORMTEXT        FORMCHECKBOX  Other:  FORMTEXT        FORMCHECKBOX  Group Home:  FORMTEXT        FORMCHECKBOX  Child Caring Institution:  FORMTEXT         FORMCHECKBOX  ADOPTION  FORMCHECKBOX  To be finalized in Sending State  FORMCHECKBOX  To be finalized in Receiving State  FORMCHECKBOX  Subsidy / IV-E Assistance Legal Status:  FORMCHECKBOX  Sending Agency Custody/Guardianship  FORMCHECKBOX  Parent Relative Custody/Guardianship  FORMCHECKBOX  Court Jurisdiction Only   FORMCHECKBOX  Parental Rights Terminated-Right to Place for Adoption  FORMCHECKBOX  Unaccompanied Refugee Minor  FORMCHECKBOX  Other:  FORMTEXT       SECTION III  SERVICES REQUESTEDInitial Report (if applicable)  FORMCHECKBOX  Parent Home Study  FORMCHECKBOX  Relative Home Study  FORMCHECKBOX  Adoptive Home Study  FORMCHECKBOX  Foster Home StudySupervisory 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"$&<>Z\^,.BDFPR`bнЫr_ЫJr(jhqpe>*CJOJQJU^J%j8hqpeCJOJQJU^J-jhqpe>*CJOJQJU^JmHnHu(jhqpe>*CJOJQJU^Jhqpe>*CJOJQJ^J"jhqpe>*CJOJQJU^J%jNhqpeCJOJQJU^JhqpeCJOJQJ^JjhqpeCJOJQJU^J%jhqpeCJOJQJU^Jb~$&:<>HJLPs^Ohqpe5CJOJQJ\^J(jhqpe>*CJOJQJU^J%jhqpeCJOJQJU^J-jhqpe>*CJOJQJU^JmHnHu(jhqpe>*CJOJQJU^Jhqpe>*CJOJQJ^J"jhqpe>*CJOJQJU^JjhqpeCJOJQJU^J%j"hqpeCJOJQJU^JhqpeCJOJQJ^JPRnpr  ./=>?AZ[\]ݱݥvc݉Thqpe5CJOJQJ\^J%j\hqpeCJOJQJU^J%jhqpeCJOJQJU^JhqpeCJOJQJ^JjhqpeCJOJQJU^JhqpeCJOJQJ^J+jphqpe5CJOJQJU\^J+jhqpe5CJOJQJU\^Jhqpe5CJOJQJ\^J%jhqpe5CJOJQJU\^J\]kR$Ifqkd$$Ifl40 *|064 laf4 ]klz{|~ RSabceնգնՐնnն[ն%jShqpeCJOJQJU^J%jhqpeCJOJQJU^Jhqpe5CJOJQJ\^J%jghqpeCJOJQJU^J%jhqpeCJOJQJU^JhqpeCJOJQJ^J%j{hqpeCJOJQJU^JhqpeCJOJQJ^JjhqpeCJOJQJU^Jhqpe5CJOJQJ\^J#  TVųzmaRNR?hqpe5CJOJQJ\^Jhqpehqpe5CJOJQJ\^JhqpeCJOJQJ^Jhqpe>*CJOJQJ^J-jhqpe>*CJOJQJU^JmHnHu(j?hqpe>*CJOJQJU^Jhqpe>*CJOJQJ^J"jhqpe>*CJOJQJU^JhqpeCJOJQJ^JjhqpeCJOJQJU^J%jhqpeCJOJQJU^JhqpeCJOJQJ^JT$Ifqkd$$Ifl40*064 laf4TV,zrNNOfOOO"P$If$Ifmkdz$$Ifl4*+   064 laf4p *,.JLNRxz|N NNNNrNtNNбОЋЇЅr%jhqpeCJOJQJU^JUhqpe%jhqpeCJOJQJU^J%j hqpeCJOJQJU^J%jhqpeCJOJQJU^JhqpeCJOJQJ^JhqpeCJOJQJ^JjhqpeCJOJQJU^J%jhqpeCJOJQJU^J%CKBOX  Request Receiving State to Arrange Supervision  FORMCHECKBOX  Another Agency Agreed to Supervise  FORMCHECKBOX  Sending Agency to Supervise Supervisory Reports  FORMCHECKBOX  Quarterly  FORMCHECKBOX  Semi-Annually  FORMCHECKBOX  Upon Request  FORMCHECKBOX  Other:  FORMTEXT      Name and Address of Supervising Agency in Receiving State:  FORMTEXT      Enclosed:  FORMCHECKBOX  Child s Social History  FORMCHECKBOX  Court Order  FORMCHECKBOX  Home Study of Placement Resource  FORMCHECKBOX  IV-E Documentation  FORMCHECKBOX  Financial / Medical Plan  FORMCHECKBOX  Other:  FORMTEXT      Signature of Sending Agency or Person: Date: Signature of Sending Sate Compact Administrator, Deputy or Alternate:Date: SECTION IV  ACTION BY RECEIVING STATE FORMCHECKBOX  Placement may be made  FORMCHECKBOX  Placement shall not be madeREMARKS:Signature of Receiving State Compact Administrator, Deputy or Alternate:Date: Distribution: Sending Agency retains a copy and forwards completed originals plus 4 copies to: Sending Compact Administrator, DCA, or alternate who retains a copy and forwards completed original and 3 copies to: Receiving Agency Compact Administrator, DCA, or alternate who indicates action (Section IV) and forwards a copy to receiving agency and the completed original and 1 copy to sending Compact Administrator, DCA, or alternate within 30 days. Sending Compact Administrator, DCA, or alternate retains a completed copy and forwards the completed the original to the sending agency. 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