XML Workgroup

Interstate Compact Placement Request (100A)

#	DATA ELEMENT	DEFINITION
MAILING INFORMATION SECTION
1	Receiving State Compact Administrator Name	Receiving State Compact Administrator first and last name who receives the ICPC request
2	Street Address	Receiving State Compact Administrator Street Address
3	2nd Line Street Address	Receiving State Compact Administrator Street Address
4	City	Receiving State Compact Administrator City
5	State	Receiving State Compact Administrator State
6	Zip Code	Receiving State Compact Administrator State Zip Code
7	Sending State Compact Administrator	Sending State Compact Administrator First and Last Name


8	Street Address	Sending State Compact Administrator Street Address
9	2nd Line Street Address	Sending State Compact Administrator Street Address
10	City	Sending State Compact Administrator City
11	State	Sending State Compact Administrator State
12	Zip Code	Sending State Compact Administrator State Zip Code
SECTION I-IDENTIFYING DATA
13	Name of Child	First, Middle Initial, Last name of child to placed


14	Sex	Gender of child to be placed
15	Date of Birth	Date of Birth of child to be placed
16	Ethnic Group	Ethnic Group of child to be placed
17	Name of Mother	First, Middle Initial, Last name of the mother of the child to be placed


18	Name of Father	First, Middle Initial, Last name of the father of the child to be placed


19	Name of Person Responsible For Planning For Child	First, Middle Initial, Last Name of Person Responsible For Planning For Child


20	Agency Responsible For Planning For Child	Agency Name Responsible For Planning For Child
21	Telephone Number	Area Code and Telephone Number of the person or agency responsible for the child

22	Street Address	Street Address Line 1 of the person or agency responsible for the child
23	Street Address	Street Address Line 2 of the person or agency responsible for the child
24	City	Name of the city of the person or agency responsible for the child
25	State	Name of the state of the person or agency responsible for the child
26	Zip Code	Zip Code of the person or agency responsible for the child
27	Name of Person Financially Responsible For The Child	First, Middle Initial, Last Name of Person Financially Responsible For For Child


28	Name of the Agency Financially Responsible For The Child	Agency Name Financially Responsible For Planning For Child
29	Telephone Number	Area Code and Telephone Number of the person or agency financially responsible for the child

30	Street Address	Street Address Line 1 of the person or agency financially responsible for the child
31	Street Address	Street Address Line 2 of the person or agency financially responsible for the child
32	City	City of the person or agency financially responsible for the child
33	State	State of the person or agency financially responsible for the child
34	Zip Code	Zip Code of the person or agency financially responsible for the child
SECTION II-PLACEMENT INFORMATION
35	Name of Person(s) Child Is To Be Placed With	First, Middle Initial, Last Name of Person who child is to be placed with C18


36	Name of Facility Child Is To Be Placed With	Facility Name Responsible who child is to be placed with
37	Telephone Number	Area Code and Telephone Number who child is to be placed with

38	Street Address	Street Address Line 1 of the person or agency who child is to be placed with
39	Street Address	Street Address Line 2 of the person or agency who child is to be placed with
40	City	City of the person or agency who child is to be placed with
41	State	State of the person or agency who child is to be placed with
42	Zip Code	Zip Code of the person or agency who child is to be placed with
43	Type of Care-Foster Family Care	Type of placement care where the child will be placed
44	Type of Care-Group Home Care	Type of placement care where the child will be placed
45	Type of Care-Residential Treatment Center	Type of placement care where the child will be placed
46	Type of Care-Child Caring Institution	Type of placement care where the child will be placed
47	Type of Care-Institutional Care Article (VI)	Type of placement care where the child will be placed
48	Type of Care-Parent	Type of placement care where the child will be placed
49	Type of Care-Relative (Not Parent)	Type of placement care where the child will be placed
50	Relationship	Relationship of the Non-Parent Relative where the child will be placed
51	Adoption	Type of placement care where the child will be placed
52	Subsidy/IV-E Assistance	Will the adoptive parent receive adoption subsidy Title IV-E payments
53	Adoption Subsidy Title IV-E To Be Completed In Sending State	Identifies if the sending state will be responsible to complete and issue the Title IV-E subsidy payment
54	Adoption To Be Completed in Receiving State	Identifies if the receiving state will be responsible to complete and issue the Title IV-E subsidy payment
55	Is the child Title IV-E Eligible?	Identifies if the child has been determined to be eligible for Title IV-E
56	Legal Status-Sending Agency Custody/Guardianship	Identifies who has legal status of the child
57	Legal Status-Parent Relative Custody/Guardiaship	Identifies who has legal status of the child
58	Legal Status-Court Jurisdiction Only	Identifies who has legal status of the child
59	Legal Status-Parent Rights Terminated-Right To Place For Adoption	Identifies who has legal status of the child
60	Legal Status-Unaccompanied Refugee Minor	Identifies who has legal status of the child
SECTION III-SERVICES REQUESTED
61	Initial Report Requested-Parent Home Study	Sending State requests a completed parent home study
62	Initial Report Requested-Relative Home Study	Sending State requests a completed relative home study
63	Initial Report Requested-Adoption Home Study	Sending State requests a completed adoption home study
64	Initial Report Requested-Foster Home Study	Sending State requests a completed foster home study
65	Supervisory Services Requested-Request Receiving To Arrange Supv.	Sending State requests that the receiving state arranges supervision of the placement
66	Supervisory Services Requested-Another Agency Agreed To Supv.	Sending State requests that another agency has agreed to conduct the supervision of the placement
67	Supervisory Services Requested-Sending Agency To Supv.	Sending State requests that the sending agency has agreed to supevise the placement of their child
68	Supervisory Reports-Quarterly	Sending agency will send a quarterly supevisory report
69	Supervisory Reports-Semi-Annually	Sending agency will send a semi-annual supevisory report
70	Supevisory Reports-Upon Request	Sending agency will send the supevisory reports, upon request
71	Name of Supevisory Agency	Name of the Agency Supevising the placement
72	Street Address	Street Address Line 1 of the agency responsible for supervision
73	Street Address	Street Address Line 2 of the agency responsible for supervision
74	City	City of the of the agency responsible for supervision
75	State	State of the agency responsible for supervision
76	Zip Code	Zip Code of the agency responsible for supervision
77	Child's Social History	Is the Child's Social History attached?
78	Home Study of Placement Resource	Is the Home Study of the Placement Resource attached
79	Court Order	Is the Court Order for the child placed attached
80	Other Enclosures	Identifies what other pertinent enclosures are attached for ICPS review
81	Name of Sending Person or Agency Signature	Name of sending agency or person who signed the 100A
82	Date Signed	Date that the sending Agency or Person signed the 100A
83	Name of Sending State Adminstrative or Alternate Signature	Name of sending State Administrator or Alternate who signed the 100A


84	Date Signed	Date that the sending State Administrator or Alternate signed the 100A
SECTION IV-ACTION BY RECEIVING STATE
85	Placement May Be Made	Placement decision from the receiving state
86	Placement Shall Not Be Made	Placement decision from the receiving state
87	Remarks	Narrative text comments from the receiving state regarding to the placement decision
88	Signature of Sending State Compact Administrator or Alternate	Name of receiving State Compact Administrator or Alternate who is authorizing the placement decision
89	Date Signed	Date that the receiving State Compact Administrator or Alternate made the placement decision

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