Form DHS-3039 (ICJ Form V) "Interstate Compact for Juveniles Report of Sending State Upon Parolee or Probationer Being Sent to the Receiving State" - Michigan

What Is Form DHS-3039 (ICJ Form V)?

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-3039 (ICJ Form V) 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-3039 (ICJ Form V) "Interstate Compact for Juveniles Report of Sending State Upon Parolee or Probationer Being Sent to the Receiving State" - Michigan

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INTERSTATE COMPACT FOR JUVENILES
FORM V
REPORT OF SENDING STATE UPON PAROLEE OR PROBATIONER
BEING SENT TO THE RECEIVING STATE
Michigan Department of Human Services
TO:
DATE:
(Receiving State)
FROM:
(Sending State)
(County)
RE:
(Name of Juvenile)
(Date of Birth)
(Race)
(Sex)
The above-named juvenile
will depart OR
has departed from sending state by
(Mode of Transportation)
on
and was instructed to report
in person
by telephone OR
by letter, within 48 hours of
(Date)
arrival in the receiving state to:
Name:
Telephone: (
)
Address
(Street Address)
(City)
(State)
(Zip)
Enclosed please find: (please check applicable items)
Parole or probation sanctions
Other material as follows:
Please acknowledge receipt of this form and send arrival report as soon as possible.
Signed:
Title:
Agency:
DHS-3039 (Rev. 1-11) Previous edition obsolete. MS Word
1
(Form V)
INTERSTATE COMPACT FOR JUVENILES
FORM V
REPORT OF SENDING STATE UPON PAROLEE OR PROBATIONER
BEING SENT TO THE RECEIVING STATE
Michigan Department of Human Services
TO:
DATE:
(Receiving State)
FROM:
(Sending State)
(County)
RE:
(Name of Juvenile)
(Date of Birth)
(Race)
(Sex)
The above-named juvenile
will depart OR
has departed from sending state by
(Mode of Transportation)
on
and was instructed to report
in person
by telephone OR
by letter, within 48 hours of
(Date)
arrival in the receiving state to:
Name:
Telephone: (
)
Address
(Street Address)
(City)
(State)
(Zip)
Enclosed please find: (please check applicable items)
Parole or probation sanctions
Other material as follows:
Please acknowledge receipt of this form and send arrival report as soon as possible.
Signed:
Title:
Agency:
DHS-3039 (Rev. 1-11) Previous edition obsolete. MS Word
1
(Form V)
INSTRUCTIONS FOR COMPLETING ICJ FORM V
PLEASE TYPE OR PRINT LEGIBLY:
When to complete this form: This form is to be completed if the juvenile is not already in the receiving state
on all transfer of supervision cases. In the case of a juvenile probationer departing to the receiving state prior
to the referral materials being sent to the receiving state’s ICJ Office and the case is, therefore, unknown to
the receiving state, the juvenile must be instructed to continue reporting to the sending state’s probation
officer. The “Out-of-State Travel Permit and Agreement to Return” form is used as a supplement to the Form
V. It is the responsibility of the supervising probation officer to ensure that the juvenile receives a copy of the
Travel Permit and that s/he is instructed to carry it on his/her person at all times until supervision is picked up
in the receiving state.
Rule 4-103.1: Cooperative supervision shall not be provided without written approval form the receiving
state’s ICJ Office. The sending state shall maintain responsibility until supervision is accepted by the
receiving state.
Receiving state: state in which juvenile is residing or will reside.
Sending state: state of probation/parole/adjudication; state requesting cooperative supervision services.
Juvenile name, etc.: insert juvenile’s name and vital information as indicated.
Check the appropriate box: “plans to depart” OR “has departed” sending state; insert mode of transportation;
insert date of departure; check one: “in person” OR “by telephone” OR “by letter.”
Complete reporting instructions as indicated on receiving state’s report.
Check as applicable any enclosures.
Signed: The form is to be signed by the sending state’s case worker or parole/probation officer; insert title
and agency of signer as requested.
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-3039 (Rev. 1-11) Previous edition obsolete. MS Word
2
DISTRIBUTION: Original and 2 copies to Michigan Compact
(Form V)
Office
Copy – County File
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