Form DHS-3038 (ICJ Form IV) "Interstate Compact for Juveniles Parole or Probation Investigation Request" - Michigan

What Is Form DHS-3038 (ICJ Form IV)?

This is a legal form that was released by the Michigan Department of Health and Human Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS-3038 (ICJ Form IV) by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DHS-3038 (ICJ Form IV) "Interstate Compact for Juveniles Parole or Probation Investigation Request" - Michigan

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INTERSTATE COMPACT FOR JUVENILES
FORM IV
PAROLE OR PROBATION INVESTIGATION REQUEST
Michigan Department of Human Services
DATE:
TO:
FROM:
(Receiving State)
(Sending State)
Name of Juvenile:
DOB:
Race:
Sex:
Status:
Parole
Probation
Sending State File #
To reside with:
OR
Is residing with:
(Name)
Relationship:
Telephone:
(
)
Address:
City/State:
Zip:
Reason for Adjudication/Commitment:
Date of Adjudication:
Date of Commitment:
Minimum Parole/Probation
Maximum Parole/Probation
Expiration Date:
Expiration Date:
Anticipated Placement Date:
Present Location:
We desire to transfer this juvenile on
parole
probation to your state:
Because his/her parent/legal guardian resides in your state.
For the following reasons, with your consent:
Other Comments:
THE FOLLOWING MATERIALS ARE ENCLOSED:
Cover letter
FOR ICJ USE ONLY
IA/VI Application for Compact Services and Memorandum of
Understanding and Waiver
Petition(s)
Order of Adjudication and Disposition
Legal and Social History
Signed:
Parole/Probation Conditions (Agreement)
(Compact Official/Designee)
School Transcript/Records
Immunization Records
Title:
Any other Pertinent Information
Referred by:
(Name – Please Print)
Referring Agency:
Department of Human Services (DHS) will not discriminate against any individual or group
AUTHORITY: Public Act 56, 2003
because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual
COMPLETION: Required.
orientation, gender identity or expression, political beliefs or disability. If you need help with
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to
PENALTY: Juvenile may not be returned.
make your needs known to a DHS office in your area.
DHS-3038 (Rev. 1-11) Previous edition obsolete. MS Word
DISTRIBUTION: Original – Receiving State Local Office
1
(ICJ FORM IV)
Copy – Receiving State Compact Office
Copy – Michigan Compact Office
Copy – Local DHS Office
INTERSTATE COMPACT FOR JUVENILES
FORM IV
PAROLE OR PROBATION INVESTIGATION REQUEST
Michigan Department of Human Services
DATE:
TO:
FROM:
(Receiving State)
(Sending State)
Name of Juvenile:
DOB:
Race:
Sex:
Status:
Parole
Probation
Sending State File #
To reside with:
OR
Is residing with:
(Name)
Relationship:
Telephone:
(
)
Address:
City/State:
Zip:
Reason for Adjudication/Commitment:
Date of Adjudication:
Date of Commitment:
Minimum Parole/Probation
Maximum Parole/Probation
Expiration Date:
Expiration Date:
Anticipated Placement Date:
Present Location:
We desire to transfer this juvenile on
parole
probation to your state:
Because his/her parent/legal guardian resides in your state.
For the following reasons, with your consent:
Other Comments:
THE FOLLOWING MATERIALS ARE ENCLOSED:
Cover letter
FOR ICJ USE ONLY
IA/VI Application for Compact Services and Memorandum of
Understanding and Waiver
Petition(s)
Order of Adjudication and Disposition
Legal and Social History
Signed:
Parole/Probation Conditions (Agreement)
(Compact Official/Designee)
School Transcript/Records
Immunization Records
Title:
Any other Pertinent Information
Referred by:
(Name – Please Print)
Referring Agency:
Department of Human Services (DHS) will not discriminate against any individual or group
AUTHORITY: Public Act 56, 2003
because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual
COMPLETION: Required.
orientation, gender identity or expression, political beliefs or disability. If you need help with
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to
PENALTY: Juvenile may not be returned.
make your needs known to a DHS office in your area.
DHS-3038 (Rev. 1-11) Previous edition obsolete. MS Word
DISTRIBUTION: Original – Receiving State Local Office
1
(ICJ FORM IV)
Copy – Receiving State Compact Office
Copy – Michigan Compact Office
Copy – Local DHS Office
INSTRUCTIONS FOR COMPLETING ICJ FORM IV
PLEASE TYPE OR PRINT LEGIBLY:
ALL MATERIALS MUST BE PROVIDED TO THE SENDING STATE’S INTERSTATE
COMPACT FOR JUVENILES OFFICE IN TRIPLICATE, AND MUST BE DIVIDED INTO
THREE SEPARATE, COMPLETE, AND IDENTICAL PACKETS FOR FORWARDING.
Receiving state: state in which juvenile is residing or will reside.
Sending state: state of probation/parole/adjudication; requesting state.
Juvenile name, etc.: insert juvenile’s name and vital information as indicated.
Status of juvenile: parole, probation or other; if other, please explain in space provided.
Sending state file #: the case number given in your office to the juvenile’s file or case.
To reside with/is residing with: check one and insert name of person(s) with whom juvenile will reside or
does reside in the receiving state. Complete information regarding full address including phone number with
area code, and relationship to the juvenile.
Reason for adjudication/commitment: fill in adjudication or pending offenses for which juvenile is to be
supervised.
Date of adjudication: insert date of court-ordered supervision of the juvenile.
Date of commitment: insert date of court-ordered commitment of the juvenile.
Minimum parole/probation period: earliest date juvenile could be released from supervision.
Maximum Parole/probation period: latest date juvenile could be released from supervision.
Anticipated placement date: approximate date juvenile is anticipated to arrive in this proposed home.
Present location: insert current location of juvenile (at the time this request for supervision is being
transmitted to the ICJ office).
(Why) we desire to transfer this juvenile. . .: if the juvenile’s parent or legal guardian resides in the state,
check the appropriate box; if the juvenile will be living with someone other than parent or legal guardian,
complete the “for the following reasons” section.
Check the appropriate boxes as to the enclosures that are being submitted with the referral packet.
All applications should have a cover letter. Include at the very minimum: ICJ Forms IV and IA/VI,
Petition/s, Order/s of Adjudication and Disposition, and Parole/Probation Conditions (Agreement). If
a social history is available, it must be included as well. All other items are helpful to the successful
investigation and supervision of this case by the proposed new state of residency.
Referred by: Printed name of caseworker or officer making this request for supervision.
Referring Agency: Print name of requester’s agency.
Signature: Form should be signed by an ICJ Compact Official or Designee.
DHS-3038 (Rev. 1-11) Previous edition obsolete. MS Word
2
(ICJ FORM IV)
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