ࡱ> XZWE@ 8bjbj "JI +HHH\    dT\"2,,3"5"5"5"5"5"5"#RP&85"QH@5""RH3"3": ,&"H! ]H F ?!"0" R&&!\\&H! stw5"5"\\ \\  INTERSTATE COMPACT REPORT ON CHILD S PLACEMENT STATUS TO:  FORMTEXT       FROM: VERMONT ICPCICPC 100B PLEASE TYPEIDENTIFYING INFORMATION Child s Name:  FORMTEXT       Mother s Name:  FORMTEXT        Birth Date:  FORMTEXT       Father s Name:  FORMTEXT        PLACEMENT STATUS  FORMCHECKBOX  Initial Placement of Child in Receiving State Date Child Placed in Receiving State:  FORMTEXT       Name:  FORMTEXT       Address:  FORMTEXT       Type of Care:  FORMTEXT        FORMCHECKBOX  Placement Change Date:  FORMTEXT        FORMCHECKBOX  Name:  FORMTEXT        FORMCHECKBOX  Address:  FORMTEXT        FORMCHECKBOX  Type of Care:  FORMTEXT        COMPACT TERMINATION  FORMCHECKBOX  Proposed Placement Request Withdrawn Name of Placement Resource:  FORMTEXT        FORMCHECKBOX  Adoption Finalized  FORMCHECKBOX  In Sending State  FORMCHECKBOX  In Receiving State  FORMCHECKBOX  Child Reached Majority/Legally Emancipated  FORMCHECKBOX  Treatment Completed  D   L N P n p ߰ęߍq^qHq*jhi-VCJOJQJU^JmHnHu%jhi-VCJOJQJU^Jjhi-VCJOJQJU^Jhi-VCJOJQJ^Jhi-VCJOJQJ^J,jhi-V5OJQJU\^JmHnHu'jhi-V5OJQJU\^J!jhi-V5OJQJU\^Jhi-VOJQJ^Jhi-V5OJQJ\^Jhi-Vjhi-VCJUmHnHuD   [kd$$IflF D*XXX06    4 la $$Ifa$$If$If ^` 88 L N P , . x $IfjkdQ$$Ifl*+   064 lap $$Ifa$      ( * , . N P d f h r t v x z | ylyhlyhi-Vhi-V5OJQJ\^Jhi-V5CJOJQJ\^J%jYhi-VCJOJQJU^J%jhi-VCJOJQJU^Jhi-VCJOJQJ^J*jhi-VCJOJQJU^JmHnHu%jqhi-VCJOJQJU^Jhi-VCJOJQJ^Jjhi-VCJOJQJU^J!x z | $Ifnkd$$Ifl0*064 la . 0 *,$IfjkdT$$Ifl*+   064 lap  . | ~ j^L?*(jhi-V>*CJOJQJU^Jhi-V>*CJOJQJ^J"jhi-V>*CJOJQJU^Jhi-VCJOJQJ^J3jhi-V5>*CJOJQJU\^JmHnHu.jhi-V5>*CJOJQJU\^Jhi-V5>*CJOJQJ\^J(jhi-V5>*CJOJQJU\^Jhi-V5CJOJQJ\^Jhi-VCJOJQJ^Jjhi-VCJOJQJU^J%jhi-VCJOJQJU^J     * , . 0 X Z n p r | ~ ʾʎʾyʾiVi%jLhi-VCJOJQJU^Jjhi-VCJOJQJU^J(jhi-V>*CJOJQJU^J(jdhi-V>*CJOJQJU^Jhi-VCJOJQJ^Jhi-V5CJOJQJ\^Jhi-VCJOJQJ^Jhi-V>*CJOJQJ^J-jhi-V>*CJOJQJU^JmHnHu"jhi-V>*CJOJQJU^J &(*,8:VXZrtٵٵqٵeRٵ%j hi-VCJOJQJU^Jhi-VCJOJQJ^J(jr hi-V>*CJOJQJU^J%j hi-VCJOJQJU^Jjhi-VCJOJQJU^Jhi-VCJOJQJ^Jhi-V>*CJOJQJ^J-jhi-V>*CJOJQJU^JmHnHu"jhi-V>*CJOJQJU^J(j: hi-V>*CJOJQJU^JBDFٵzٵeٵVIVEIVhi-Vhi-V5OJQJ\^Jhi-V5CJOJQJ\^J(jF hi-V>*CJOJQJU^J%j hi-VCJOJQJU^Jjhi-VCJOJQJU^Jhi-VCJOJQJ^Jhi-VCJOJQJ^Jhi-V>*CJOJQJ^J-jhi-V>*CJOJQJU^JmHnHu"jhi-V>*CJOJQJU^J(j\ hi-V>*CJOJQJU^JB$If[kd $$Ifl*+064 la$IfBDF,.&(001122J3N3$Ifjkd; $$Ifl*+   064 lap FHdfhl(*,.0LNPݻpdTATT%jhi-VCJOJQJU^Jjhi-VCJOJQJU^Jhi-VCJOJQJ^J-jhi-V>*CJOJQJU^JmHnHu(jMhi-V>*CJOJQJU^Jhi-V>*CJOJQJ^J"jhi-V>*CJOJQJU^Jhi-VCJOJQJ^J+j hi-V5CJOJQJU\^Jhi-V5CJOJQJ\^J%jhi-V5CJOJQJU\^J&(*FHJN00нЮvcWUUhi-VCJOJQJ^J%jhi-VCJOJQJU^J+jhi-V5CJOJQJU\^Jhi-V5CJOJQJ\^J%jhi-V5CJOJQJU\^Jhi-V5CJOJQJ\^J%jhi-VCJOJQJU^Jhi-VCJOJQJ^Jjhi-VCJOJQJU^J%j7hi-VCJOJQJU^JFORMCHECKBOX  Approved Resource Will Not Be Used For Placement  FORMCHECKBOX  Sending State s Jurisdiction Terminated  FORMCHECKBOX  Unilaterally  FORMCHECKBOX  Concurrence  FORMCHECKBOX  Child Returned to Sending State  FORMCHECKBOX  Child has moved to another State  FORMCHECKBOX  Legal Custody and/or Guardianship Awarded and/or Returned to: Name:  FORMTEXT       Relationship:  FORMTEXT        FORMCHECKBOX  Other (Specify):  FORMTEXT       Date of Termination:  FORMTEXT        SIGNATURESPerson/Agency Supplying Information:Date: Compact Administrator, Deputy or Alternate:Date: Distribution: * Sending Agency retains a copy and forwards completed original plus 3 copies to: * Sending Compact Administrator, Deputy or alternate retains a copy, forwards a copy to the sending agency, and sends completed original and 1 copy to: * Receiving Agency Compact Administrator, Deputy or alternate retains a copy and sends the completed original to the receiving agency. One form per child FRR 4/6/00 SRS-100B 000"0000000011214161j1l111111111ǻǖǻs`TA%jhi-VCJOJQJU^Jhi-VCJOJQJ^J%jmhi-VCJOJQJU^J%jhi-VCJOJQJU^Jjhi-VCJOJQJU^J+jhi-V5CJOJQJU\^Jhi-V5CJOJQJ\^Jhi-VCJOJQJ^Jhi-V5CJOJQJ\^J%jhi-V5CJOJQJU\^J+j hi-V5CJOJQJU\^J11>2@2\2^2`22222222L3N3h3j3~33333333ızmXzAzzm-jhi-V>*CJOJQJU^JmHnHu(jEhi-V>*CJOJQJU^Jhi-V>*CJOJQJ^J"jhi-V>*CJOJQJU^J+jhi-V5CJOJQJU\^Jhi-V5CJOJQJ\^J%jhi-V5CJOJQJU\^Jhi-VCJOJQJ^J%jYhi-VCJOJQJU^Jhi-VCJOJQJ^Jjhi-VCJOJQJU^J33333333444,4.4B4D4F4P4R4T4V444ٵzٵeٵVA(jhi-V5>*CJOJQJU\^Jhi-V5CJOJQJ\^J(jhi-V>*CJOJQJU^J%j1hi-VCJOJQJU^Jhi-VCJOJQJ^Jjhi-VCJOJQJU^Jhi-VCJOJQJ^Jhi-V>*CJOJQJ^J-jhi-V>*CJOJQJU^JmHnHu"jhi-V>*CJOJQJU^J(jhi-V>*CJOJQJU^JN333T4V444444$If[kd$$Ifl*+064 la$If 4444444444445 5"555577888888¨|r|rYSIhi-VB*CJph hi-VCJ0jhi-V5CJOJQJU\^JmHnHuhi-VOJQJ^Jhi-VCJOJQJ^Jhi-Vhi-V5OJQJ\^Jhi-V5CJOJQJ\^J3jhi-V5>*CJOJQJU\^JmHnHu(jhi-V5>*CJOJQJU\^J.jhi-V5>*CJOJQJU\^Jhi-V5>*CJOJQJ\^J4455 5$Ifjkd$$Ifl*+   064 lap  5"5z555$Ifnkd$$Ifl0X * D 064 la555L678888888nkdE$$Ifl0X * D 064 la 1h/ =!"#$%DText1 State referral is being sent to.$$If!vh5X5X5X#vX:V l065X/ 4$$If!vh5+#v+:V l   065+/ 4p tDText2tDText4tDText3tDText5$$If!vh55#v:V l0654$$If!vh5+#v+:V l   065+4p DeCheck2DCheck here upon initial placement of child into the receiving state.DText6GEnter the date the child was initially placed into the receiving state.tDText7tDText8tDText9DeCheck1=Check here if the child's out of state placement has changed.DText10'Enter the date of the placement change.tDeCheck3vDText11tDeCheck4vDText12tDeCheck5vDText13}$$If!vh5+#v+:V l065+4$$If!vh5+#v+:V l   065+4p tDeCheck6vDText14tDeCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12vDeCheck13vDeCheck14vDeCheck15vDeCheck16vDeCheck17vDeCheck18vDText15vDText16vDeCheck19vDText17vDText18}$$If!vh5+#v+:V l065+4$$If!vh5+#v+:V l   065+4p $$If!vh5 5D #v #vD :V l065 5D 4$$If!vh5 5D #v #vD :V l065 5D 4@@@ NormalCJ_HaJmH sH tH F@F Heading 1$@&5OJQJ\^JP@P Heading 2$@&5B*OJQJ\^Jphf@f Heading 3$-D @&M 5B*CJOJQJ\^JphV@V Heading 4$$@&a$5B*OJQJ\^JphL@L Heading 5$$@&a$5OJQJ\^JDAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List *u *-u J"@AD_s<=>OPQ@AMNBCST*+UVWXcd&I \ ] r s v @0@0@0@0@0 @0 @0@0 @0 @0 @0 @0@0@0@0 @0@0@0@0 @0 @0@0 @0 @0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0 @0@0 @0 @0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 @0 @0@0 @0 @0 @0@0 @0 @0 @0@0 @0 @0@0@0@0(@0z000@0z000| F01348 ! x BN34 558  "#$8 HTZ'39Qa,8>AQ ,9EKTdv'CSm}CS/Td"(AMSu FtFtFtFtFtG FtFtFtFtG FtG$FtG$FtG$FtG$FtG$G$G$G$G$G$G$G$G$G$G$G$FtFtG$FtFt8@>(  T  C  H  #  B S  ?u (t!+yt%Text1Text2Text4Text3Text5Check2Text6Text7Text8Text9Check1Text10Check3Text11Check4Text12Check5Text13Check6Text14Check7Check8Check9Check10Check11Check12Check13Check14Check15Check16Check17Check18Text15Text16Check19Text17Text18I(R-B:UwDnD UBv   !"#$[:b?R-Le(T~T0e)Tv a& u$| OPVWXcdv @Lu `` ` ```0UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New;Wingdings"htcE)lcEbb1"24dE E 3QH(?5mbryce   Oh+'0t  $ 0 < HT\dlssmbrycebrybryNormal rm2rmMicrosoft Word 10.0@@S B@m'C@Gb՜.+,0 hp|  SRSE   Title  !"#$%'()*+,-./012456789:;<=>?@ABCDEFHIJKLMNPQRSTUVYRoot Entry FЏrH[Data &1Table3&WordDocument"JSummaryInformation(GDocumentSummaryInformation8OCompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q