Interstate Compact on the Placement of Children (ICPC) Placement Request Use of form: Complete this form to request out-of-state placement of child(ren) per s. 48.988, Wis. Stats. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Provision of your social security number (SSN) is voluntary; not providing it could result in an information processing delay. TO: (Name of Receiving State) FROM: Wisconsin ICPC DCF/DSP P. O. Box 8916 Madison, WI 53708-8916 NOTICE IS GIVEN OF INTENT TO PLACE CHILD IDENTIFYING DATA Name Child (Last, First, MI) Case ID Birthdate Sex Social Security Number – Race/Ethnic Group ICWA Eligible Tribe Agrees with Placement IV-E Eligible No Yes No Yes No Yes Name Parent 1 Name Parent 2 – – Name Agency or Person Responsible for Planning for Child Telephone Number – Address (Street, City, State, Zip Code) – Name Agency or Person Financially Responsible for Child Address (Street, City, State, Zip Code) – – PROPOSED PLACEMENT INFORMATION Name Person or Facility Child is to be Placed With Telephone Number – Address (Street, City, State, Zip Code) – Type of Care Foster Family Care Is this placement for the purposes of adoption? Group Home Care Yes No Residential Care Center Parent Unlicensed Relative (not parent) Relationship: – Adoption to be completed in Licensed Relative (not parent) Relationship: – Sending state Receiving state Legal Status Sending Agency Custody / Guardianship Parental Rights Terminated - Right to Place for Adoption Parent Relative Custody / Guardianship (only for private RCC) Unaccompanied Refugee Court Jurisdiction Only SERVICES REQUESTED Initial Report (If applicable) Supervisory Services Supervisory Reports Quarterly Parent Home Study Request Receiving State to Arrange Supervision Monthly Another Agency Agreed to Supervise Relative Home Study Other Adoptive Home Study / Placement Foster Home Study / Placement Name Supervising Agency in Receiving State – (mm/dd/yyyy) SIGNATURE Person or Sending Agency Representative – Date Signed SIGNATURE Sending State Compact Administrator or Alternate – Date Signed (mm/dd/yyyy) ACTION BY RECEIVING STATE Remarks Placement may be made Placement shall not be made Date Signed (mm/dd/yyyy) SIGNATURE—Receiving State Compact Administrator or Alternate
Interstate Compact on the Placement of Children (ICPC) Placement Request Use of form: Complete this form to request out-of-state placement of child(ren) per s. 48.988, Wis. Stats. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Provision of your social security number (SSN) is voluntary; not providing it could result in an information processing delay. TO: (Name of Receiving State) FROM: Wisconsin ICPC DCF/DSP P. O. Box 8916 Madison, WI 53708-8916 NOTICE IS GIVEN OF INTENT TO PLACE CHILD IDENTIFYING DATA Name – Child (Last, First, MI) Case ID Birthdate Sex Social Security Number Race/Ethnic Group ICWA Eligible Yes No Tribe Agrees with Placement Yes No IV-E Eligible Yes No Name – Parent 1 Name – Parent 2 Name – Agency or Person Responsible for Planning for Child Telephone Number Address – (Street, City, State, Zip Code) Name – Agency or Person Financially Responsible for Child Address – (Street, City, State, Zip Code) PROPOSED PLACEMENT INFORMATION Name – Person or Facility Child is to be Placed With Telephone Number Address – (Street, City, State, Zip Code) Type of Care Foster Family Care Group Home Care Residential Care Center Parent Unlicensed Relative (not parent) – Relationship: Licensed Relative (not parent) – Relationship: Is this placement for the purposes of adoption? Yes No Adoption to be completed in Sending state Receiving state Legal Status Sending Agency Custody / Guardianship Parent Relative Custody / Guardianship (only for private RCC) Court Jurisdiction Only Parental Rights Terminated - Right to Place for Adoption Unaccompanied Refugee SERVICES REQUESTED Initial Report (If applicable) Parent Home Study Relative Home Study Adoptive Home Study / Placement Foster Home Study / Placement Supervisory Services Request Receiving State to Arrange Supervision Another Agency Agreed to Supervise Supervisory Reports Quarterly Monthly Other Name – Supervising Agency in Receiving State SIGNATURE – Person or Sending Agency Representative Date Signed (mm/dd/yyyy) SIGNATURE – Sending State Compact Administrator or Alternate Date Signed (mm/dd/yyyy) ACTION BY RECEIVING STATE Placement may be made Placement shall not be made Remarks SIGNATURE—Receiving State Compact Administrator or Alternate Date Signed (mm/dd/yyyy)
icpc-placement-request-100a.docx