Interstate Compact Placement Request - Form 100A

State of Tennessee Department of Children’s Services Interstate Compact on the Placement of Children 436 Sixth Avenue North 8th Floor Nashville, Tennessee 37243-1290 ICPC-100A Interstate Compact Placement Request TO: (Name and Address of Compact Administrator in Receiving State) FROM: (Name and Address of Compact Administrator in Sending State)

Section I - Identifying Data Notice is Given of Intent to Place: Sex: Date of Birth: Ethnic Group: Name of Child: Name of Mother: Name of Father: Name and Address of the Agency or Person Responsible for Planning for Child: Telephone Number:

Name and Address of the Agency or Person Financially Responsible for the Child Telephone Number:

Section II - Placement Information Name and Address of Person(s) or Facility Child is to be Placed with: Telephone Number:

TYPE OF CARE Parent Adoption Relative-Specify relationship: Subsidy/IV-E Assistance Foster Family Care Residential Treatment Center To be completed in: Group Home Care Child-caring Institution Other - Specify Sending State Institutional Care (Article VI) Receiving State LEGAL STATUS Sending Agency Custody / Guardianship Parental Rights terminated - Right to place for Adoption Parent/Relative Custody / Guardianship Unaccompanied Refugee Minor Court Jurisdiction Only/Protective Services Supervision Other - Specify: Section III -Services Requested Initial Report (if applicable): Supervisory Services: Supervisory Reports: Parent Home Study Request Receiving State to Arrange Quarterly Relative Home Study Supervision Semi-Annually Adoptive Home Study Another Agency Agreed to Supervise Upon request Foster Home Study Sending Agency to Supervise Other: Specify Other Study - Specify: Name and Address of Supervising Agency In Receiving State, If Known: Enclosed Child’s Social History Court Order Home Study of Placement Resource Other Enclosures Signature of Sending Agency or Person Date Signed

Signature of Sending State Compact Administrator or Alternate Date Signed

Section IV - Action by Receiving State Placement May be Made. Remarks: Placement Shall Not Be Made. Signature of Receiving State Compact Administrator or Alternate Date Signed

Distribution Complete six (6) copies of this form  Sending Agency retains one (1) copy of this form and forwards five (5) copies to:  Sending Compact Administrator, who retains one (1) copy and forwards four (4) copies to:  Receiving Compact Administrator, who indicates action (Section IV), retains one (1) copy, and forwards one (1) copy to receiving Agency and two (2) copies to sending Compact Administrator within 30 days.  Sending Compact Administrator retains one (1) completed copy and forwards one (1) completed copy to the Sending Agency.