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)[TM1] / FROM: Wisconsin ICPC
Division of Safety and Permanence
Bureau of Permanence and Out-of-Home Care
P. O. Box 8916
Madison, WI 53708-8916
NOTICE IS GIVEN OF INTENT TO PLACE CHILD
IDENTIFYING DATA
Name – Child (Last, First, MI)
[TM2] / Social Security No.
[TM3] / Birthdate
[TM4] / Sex
[TM5] / Ethnic Group
[TM6] / ICWA Eligible
[TM7] Yes [TM8] No / IV-E Eligible
[TM9] Yes [TM10] No
Name – Mother
[TM11] / Name - Father
[TM12]
Name – Agency or Person Responsible for Planning for Child
[TM13] / Telephone Number
[TM14]
Address - (Street, City, State, Zip Code)
[TM15]
Name – Agency or Person Financially Responsible for Child
[TM16] / Address - (Street, City, State, Zip Code)
[TM17]
PLACEMENT INFORMATION
Name – Person or Facility Child is to be Placed With
[TM18] / Telephone Number
[TM19]
Address - (Street, City, State, Zip Code)
[TM20]
Type of Care / [TM21] Parent / [TM22]Adoption
[TM23] Foster Family Care
[TM24] Group Home Care
[TM25] Residential Care Center / [TM26] / [TM27] Subsidy / IV-E Assistance
[TM28] Relative (not parent) – Specify Relationship / Adoption to be completed in -
[TM29] / [TM30] Sending state
[TM31]Receiving state
[TM32]Other – Specify
[TM33]
Legal Status
[TM34] Sending Agency Custody / Guardianship
[TM35] Parent Relative Custody / Guardianship
[TM36] Court Jurisdiction Only / [TM37] Parental Rights Terminated - Right to Place for Adoption
[TM38] Unaccompanied Refugee
[TM39] Other - Specify
[TM40]
SERVICES REQUESTED
Initial Report (If applicable)
[TM41] Parent Home Study
[TM42] Relative Home Study
[TM43] Adoptive Home Study / Placement
[TM44] Foster Home Study / Placement
[TM45]Foster / Adoption Home Study / Supervisory Services
[TM46] Request Receiving State to Arrange Supervision
[TM47] Another Agency Agreed to Supervise
[TM48] Sending Agency to Supervise / Supervisory Reports
[TM49] Quarterly
[TM50] Semiannually
[TM51] Upon Request
[TM52] Monthly
[TM53]Other
[TM54]
Name – Supervising Agency in Receiving State
[TM55]
Enclosed
[TM56] Child's Social History[TM57] Home Study of Placement Resource[TM58] Court Order[TM59] Other Enclosures
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
[TM60] Placement may be made
[TM61] Placement shall not be made / Remarks
[TM62]
SIGNATURE - Receiving State Compact Administrator or Alternate / Date Signed (mm/dd/yyyy)
ICPC Checklist to Initiate a Request for Out-of-State Home Study, Placement and Supervision of a Child
Parent, Relative, Foster or Residential Requests:Submit to ICPC THREE identical packets for EACH child, each including:
[TM63] / ICPC 100A form for each child
[TM64] / Short cover letter outlining the situation that created the removal of the child(ren) and explaining any concerns that need to be addressed in the evaluation of the proposed placement
[TM65] / Signed, valid court order establishing initial jurisdiction (CHIPS or TPC) and subsequent extension of orders, if any
[TM66] / Social history of the child and other relevant history (medical, psychological, psychiatric, educational, etc.)
[TM67] / Copy of most recent provider(s) license or approval (specific to Regulation #1 or ICWA placements(s))
[TM68] / Court Report (which usually provides information regarding the child’s social history)
[TM69] / Permanency Plan
[TM70] / Child’s IV-E eligibility printout from eWiSACWIS
[TM71] / ICPC Financial / Medical Plan (form available at
[TM72] / Regulation #2 – Mandatory Workers Statement
Supervision / Services Request or to Close Case:
Submit to ICPC THREE identical packets for EACH child, each including:
[TM73] / ICPC 100B form once placement is made (form available at
[TM74] / Change of placement order if one exists (not required)
Worker Statement Regarding Proposed Placement Resource
(In accordance with ICPC Regulation 2 and 7, revised effective 10/1/11)
Mandated Checklist
(Sign and return with each request)
Name – Caregiver(s)[TM75] / Relationship to the child
[TM76]
Social Security Number(s)
[TM77] / Birthdate(s)
[TM78]
Other Adults living in the home
[TM79]
Social Security Number(s)
[TM80] / Birthdate(s)
[TM81]
Address – Caregiver(s) (Street, City, State, Zip Code)
[TM82]
Telephone Number – Caregiver(s)
[TM83]
Number of Bedrooms in the Home
[TM84] / Number of People in the Home
[TM85]
[TM86] / I have communicated directly with the potential placement resource.
[TM87] / I confirm the potential placement resource is interested in being a placement resource for the child and is willing to cooperate with the ICPC process.
[TM88] / I am including the name and correct physical and mailing address of the placement resource and all available telephone numbers and other contact information for the potential placement resource.
[TM89] / I am including the number of bedrooms in the home of the placement resource under consideration and the number of people, including children, who will be residing in the home.
[TM90] / I am confirming the potential placement resource acknowledges that he / she has sufficient financial resources or will access financial resources to feed, clothe, and care for the child.
[TM91] / I confirm the placement resourceunderstands a criminal records and child abuse history check will be completed for any persons residing in the home required to be screened under the laws of the receiving state.
Name – Caseworker (Print)
[TM92] / SIGNATURE – Caseworker / Date Signed
Telephone Number – Caseworker
[TM93] / Alternative Telephone Number – Caseworker
[TM94]
ICPC Checklist for Adoption Requests
Adoptive Home Study and Conversion Requests:Submit to ICPC THREE identical packets for EACH child, each including:
[TM95] / ICPC 100A form requesting adoptive home study
[TM96] / TPR and all other court orders / legal documents on child
[TM97] / Complete social / medical / psych / educational history on child
[TM98] / IV-E documentation on child
[TM99] / Financial / Medical Plan
[TM100] / Cover Letter
[TM101] / If first-time adoptive parent(s) provide certificate of completion for first-time adoptive parent training.
Newborn Adoptive Placement Requests: (WI does not accept UNBORN baby requests)
Submit to ICPC THREE identical packets for EACH child, each including:
[TM102] / ICPC 100A form requesting adoptive placement
[TM103] / TPR order (needed if finalizing in Wisconsin) or Relinquishment plus signed legal risk placement agreement
[TM104] / Family History Questionnaire – Medical / Genetic DCF-F-CFS0149 signed by birthparents or explanation if both parents have not completed this form
[TM105] / Family History Questionnaire – Medical / Genetic / Pregnancy and Delivery Information DCF-F-CFS0149A
[TM106] / Hospital Records: Medical Records, Discharge Summary
[TM107] / Social History of Birth Mother and Birth Father
[TM108] / Birth Parents Counseling Summary
[TM109] / Report to the Court
[TM110] / Current Adoptive Home Study
[TM111] / Private Adoptions Only: Statement of Expenses Paid to Birth Parent(s) by Adoptive Parent(s)
[TM112] / Other: Any other documentation to meet the requirements of another state
[TM113] / Overnight mailing envelope for the receiving state with postage to contain two (2) copies of request
[TM114] / Send this information via OVERNIGHT MAIL ONLY to:
Wisconsin ICPC
Department of Children and Families
Division of Safety and Permanence / ICPC
201 E. Washington Ave., Rm. E200
Madison, WI 53703
Older Children Adoptive Placement Requests:
Submit to ICPC THREE identical packets for EACH child, each including:
[TM115] / Regulation #2 – Mandatory Workers Statement
[TM116] / ICPC Financial / Medical Plan (form available at
[TM117] / ICPC 100A form requesting adoptive placement
[TM118] / TPR order (needed if finalizing in Wisconsin) or Relinquishment
[TM119] / Social History of Birth Mother and Birth Father
[TM120] / Report to the Court
[TM121] / Current Adoptive Home Study
[TM122] / Current Foster Home License
[TM123] / Documentation of 3 pre-adoptive placement visits (for special needs children only)
[TM124] / If first-time adoptive parent(s) provide certificate of completion for first-time adoptive parent training.
[TM125] / Other: Any other documentation to meet the requirements of another state
Supervision / Services Request or to Close Case:
Submit to ICPC THREE identical packets for EACH child, each including:
[TM126] / ICPC 100B form once placement is made (form available at
[TM127] / Change of placement order or adoption decree if one exists
ICPC Placement Request Page 1 of 3
DCF-F-CFS0100A-E(ICPC100A)(R. 10/2013)
[TM1]This field is user-entered. This field is editable on the template.
[TM2]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the child’s Name can be changed in the First/Last Name fields on the Basic tab of the Person Management page.
[TM3]The field is pre-filled.
The field is not editable on the template.
The data can be corrected as follows: thechild's social security number can be changed on the Basic tab of the Person Management page.
[TM4]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the child’s birth date can be changed in the Birth Date field on the Basic tab of the Person Management page.
[TM5]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the child’s gendercan be changed in the Gender field on the Basic tab of the Person Management page.
[TM6]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the child’s racecan be changed in the Race field on the Basic tab of the Person Management page.
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The data can be corrected as follows: the mother's name can be changed on the mother's Basic tab of the Person Management page. A new person can be selected as Child's Mother on the Parent Info tab of the child's Person Management page.
[TM12]This field is pre-filled.
The field is not editable on the template.
The data can be corrected as follows: the father's name can be changed on the father's Basic tab of the Person Management page. A new person can be selected as Child's Father on the Parent Info tab of the child's Person Management page.
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