Interstate Compact Placement Request
(100B)
| MAILING INFORMATION SECTION |
| # |
DATA ELEMENT |
DEFINITION |
| 1 |
Receiving State Compact Administrator Name |
Receiving State Compact Administrator first
and last name who receives the ICPC request |
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| 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 |
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| |
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| 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 |
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| 14 |
Date of Birth |
Date of Birth of child to be placed |
| 15 |
Name of Mother |
First, Middle Initial, Last name of the mother
of the child to be placed |
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| 16 |
Name of Father |
First, Middle Initial, Last name of the father
of the child to be placed |
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| 17 |
Name of Placement Resources |
First, Middle Initial, Last Name of Placement
Resources |
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| SECTION II-PLACEMENT
STATUS |
| 18 |
Placement Request Withdrawn |
Placement Request Withdrawn |
| 19 |
Date |
Month, Day, and Year of the Request For Placement
Withdrawal |
| 20 |
Initial Placement Made With |
First, Middle Initial, Last Name of Who The
Child Was Placed With |
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| 21 |
Name of Facility Child Is To Be Placed With |
Facility Name Responsible who child is to
be placed with |
| 22 |
Date |
Month, Day, and Year that the child was placed |
| 23 |
Street Address |
Street Address Line 1 of the person or agency
who child is to be placed with |
| 24 |
Street Address |
Street Address Line 2 of the person or agency
who child is to be placed with |
| 25 |
City |
City of the person or agency who child is
to be placed with |
| 26 |
State |
State of the person or agency who child is
to be placed with |
| 27 |
Zip Code |
Zip Code of the person or agency who child
is to be placed with |
| 28 |
Type of Care-Foster Family Care |
Type of placement care where the child was
placed |
| 29 |
Type of Care-Group Home Care |
Type of placement care where the child was
placed |
| 30 |
Type of Care-Residential Treatment Center |
Type of placement care where the child was
placed |
| 31 |
Type of Care-Child Caring Institution |
Type of placement care where the child was
placed |
| 32 |
Type of Care-Institutional Care Article (VI) |
Type of placement care where the child was
placed |
| 33 |
Type of Care-Parent |
Type of placement care where the child was
placed |
| 34 |
Type of Care-Relative (Not Parent) |
Type of placement care where the child was
placed |
| SECTION III-COMPACT TERMINATION |
| 35 |
Reason-Adoption Finalized-In Receiving State
|
Reason for the termination of the placement |
| 36 |
Reason-Adoption Finalized In Sending State |
Reason for the termination of the placement |
| 37 |
Reason-Child Reaches Majority/Legally Emancipated |
Reason for the termination of the placement |
| 38 |
Reason-Legal Custody and/or Guardianship
Awarded and/or Returned To |
Reason for the termination of the placement |
| 39 |
Name of Person |
First, Middle Initial, Last Name of Who The
Person who has Legal Custody and/or Guardianship Awarded and/or
Returned to |
| 40 |
Relationship To Child |
Relationship of the Person who has Legal
Custody and/or Guardianship Awarded and/or Returned to |
| 41 |
Reason-Treatment Completed |
Reason for the termination of the placement |
| 42 |
Reason-Sending State's Jurisdication Terminated |
Reason for the termination of the placement |
| 43 |
Unilaterally |
Sending State Has Unilaterally Terminated
Jurisdiction |
| 44 |
Reason-Child Returned to Sending State |
Reason for the termination of the placement |
| 45 |
Reason-Approved Resource Will Not Be Used
For Placement |
Reason for the termination of the placement |
| 46 |
Date of Termination |
Month, Day, and Year that the child placedment
was/is terminated |
| 47 |
Person/Agency Supplying Information |
First, Middle Initial, Last Name or Agency
Name of the Person Completing Form |
| 48 |
Date |
Month, Day, and Year that the information
is being supplied on the 100B |
| 49 |
Reporting Compact Administrator or Alternate |
First, Middle Initial, Last Name of the Reporting
Compact Administrator or Alternate |
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| 50 |
Date |
Month, Day, and Year that the Reporting Compact
Administrator or Alternate Completed the 100B |
