Form DHS-3040 (ICJ Form IA; ICJ Form VI) "Interstate Compact for Juveniles Application for Services and Waiver" - Michigan

What Is Form DHS-3040 (ICJ Form IA; ICJ Form VI)?

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 March 1, 2012;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS-3040 (ICJ Form IA; ICJ Form VI) 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-3040 (ICJ Form IA; ICJ Form VI) "Interstate Compact for Juveniles Application for Services and Waiver" - Michigan

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FORM IA/VI
INTERSTATE COMPACT FOR JUVENILES
APPLICATION FOR SERVICES AND WAIVER
Michigan Department of Human Services
Form IA
APPLICATION FOR COMPACT SERVICES
TO:
FROM:
(Receiving State)
(Sending State)
I,
, hereby apply for supervision as a parolee or probationer to the Interstate
Compact for Juveniles. I understand that the very fact that supervision will be in another state makes it likely that there
will be certain differences between the supervision I would receive in this state and supervision which I will receive in
any state to which I am asking to go. However, I urge the authorities to whom this application is made, and all other
judicial and administrative authorities, to recognize that supervision in another state, if granted as requested in this
application, will be a benefit to me and will improve my opportunities to make a good adjustment. In order to get the
advantages of supervision under the Interstate Compact for Juveniles, I do hereby accept such differences in the
course and character of supervision as may be provided, and I do state that I consider the benefits of supervision under
the Compact to be worth any adjustments in my situation which may be occasioned.
In view of the above, I do hereby apply for permission to be supervised on
parole
probation in
(Receiving State)
Form VI
MEMORANDUM OF UNDERSTANDING AND WAIVER
I,
, realize that the grant of
parole
probation and especially the privilege to
leave the State of
to go to the State of
is a benefit to me. In return for
these advantages, I promise:
1. That I will make my home with
(Name, Relationship, and Address)
until a change of residence is duly authorized by the proper authorities of the receiving state.
parole
probation as fixed by both the
2. That I will obey and live up to the terms and conditions of
sending and receiving states. I understand and accept that a failure to comply with these terms and conditions may
result in sanctions in the sending or receiving state. See, Rule 4-104(1) and (2).
parole
probation authorities in
3. That I will return at any time to the sending state if asked to do so by the
that state. I further understand that if I do not obey or live up to these promises, I may be returned to the sending state.
I have read the above or have had the above read and explained to me, and I understand its meaning and agree thereto.
(Juvenile’s Signature)
(Date)
(Witness’ Signature)
(Date)
I, in my capacity as the placement resource for
do approve and subscribe
(Juvenile’s Name)
to the above Memorandum of Understanding and hereby waive any right which I may have to contest the return of the
juvenile referred to herein to the sending state or jurisdiction from any state or jurisdiction within or outside the United
States, in which
he
she may be found. I also undertake to cooperate with the supervising authorities and to assist
them in securing the return of the juvenile referred to herein to the sending state whenever, in their judgment, such
return may be necessary or desirable.
(Placement Resource’s Signature)
(Date)
(Witness’ Signature)
(Date)
Permission is hereby granted to the above-named juvenile to apply for, reside in, and be supervised by the State of
provided that the receiving state accepts supervision and the juvenile
complies with the terms of supervision.
(Receiving State)
(Date)
(If probation, sending state’s JUDGE;
If parole, sending state’s COMPACT OFFICIAL)
Department of Human Services (DHS) will not discriminate against any individual or group because of race,
AUTHORITY: Public Act 56, 2003
religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or
COMPLETION: Required.
expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the
PENALTY: Placement may not occur.
Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
DHS-3040 (Rev. 3-12) Previous edition obsolete. MS Word
1
(Form IA)
FORM IA/VI
INTERSTATE COMPACT FOR JUVENILES
APPLICATION FOR SERVICES AND WAIVER
Michigan Department of Human Services
Form IA
APPLICATION FOR COMPACT SERVICES
TO:
FROM:
(Receiving State)
(Sending State)
I,
, hereby apply for supervision as a parolee or probationer to the Interstate
Compact for Juveniles. I understand that the very fact that supervision will be in another state makes it likely that there
will be certain differences between the supervision I would receive in this state and supervision which I will receive in
any state to which I am asking to go. However, I urge the authorities to whom this application is made, and all other
judicial and administrative authorities, to recognize that supervision in another state, if granted as requested in this
application, will be a benefit to me and will improve my opportunities to make a good adjustment. In order to get the
advantages of supervision under the Interstate Compact for Juveniles, I do hereby accept such differences in the
course and character of supervision as may be provided, and I do state that I consider the benefits of supervision under
the Compact to be worth any adjustments in my situation which may be occasioned.
In view of the above, I do hereby apply for permission to be supervised on
parole
probation in
(Receiving State)
Form VI
MEMORANDUM OF UNDERSTANDING AND WAIVER
I,
, realize that the grant of
parole
probation and especially the privilege to
leave the State of
to go to the State of
is a benefit to me. In return for
these advantages, I promise:
1. That I will make my home with
(Name, Relationship, and Address)
until a change of residence is duly authorized by the proper authorities of the receiving state.
parole
probation as fixed by both the
2. That I will obey and live up to the terms and conditions of
sending and receiving states. I understand and accept that a failure to comply with these terms and conditions may
result in sanctions in the sending or receiving state. See, Rule 4-104(1) and (2).
parole
probation authorities in
3. That I will return at any time to the sending state if asked to do so by the
that state. I further understand that if I do not obey or live up to these promises, I may be returned to the sending state.
I have read the above or have had the above read and explained to me, and I understand its meaning and agree thereto.
(Juvenile’s Signature)
(Date)
(Witness’ Signature)
(Date)
I, in my capacity as the placement resource for
do approve and subscribe
(Juvenile’s Name)
to the above Memorandum of Understanding and hereby waive any right which I may have to contest the return of the
juvenile referred to herein to the sending state or jurisdiction from any state or jurisdiction within or outside the United
States, in which
he
she may be found. I also undertake to cooperate with the supervising authorities and to assist
them in securing the return of the juvenile referred to herein to the sending state whenever, in their judgment, such
return may be necessary or desirable.
(Placement Resource’s Signature)
(Date)
(Witness’ Signature)
(Date)
Permission is hereby granted to the above-named juvenile to apply for, reside in, and be supervised by the State of
provided that the receiving state accepts supervision and the juvenile
complies with the terms of supervision.
(Receiving State)
(Date)
(If probation, sending state’s JUDGE;
If parole, sending state’s COMPACT OFFICIAL)
Department of Human Services (DHS) will not discriminate against any individual or group because of race,
AUTHORITY: Public Act 56, 2003
religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or
COMPLETION: Required.
expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the
PENALTY: Placement may not occur.
Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
DHS-3040 (Rev. 3-12) Previous edition obsolete. MS Word
1
(Form IA)
INSTRUCTIONS FOR COMPLETING ICJ FORM IA/VI
PLEASE TYPE OR PRINT LEGIBLY.
ALL MATERIALS MUST BE PROVIDED TO THE SENDING STATE’S INTERSTATE
COMPACT ON JUVENILES OFFICE IN TRIPLICATE, AND MUST BE DIVIDED
INTO THREE SEPARATE, COMPLETE AND IDENTICAL PACKETS FOR FORWARDING.
Form IA – Application for Compact Services
Receiving state: state in which juvenile is residing or will reside.
Sending state: state of probation/parole/adjudication; requesting state.
“I…” (blank): print juvenile’s name here.
“In view of the above…”: Check either “parole” or “probation” and fill in the name of the receiving state.
Form VI – Memorandum of Understanding and Waiver
“I,…” (blank): insert juvenile’s name, check “parole” or “probation,” fill in the name of the state under whose
jurisdiction the juvenile is placed, and the name of the state in which the juvenile is residing or will reside.
“1”: insert name, relationship, and address of home offer wherein juvenile is residing or will reside.
“2”: check either “parole” or “probation.”
“3”: check either “parole” or “probation;” Juvenile must sign and date; witness must sign and date.
“I, in my capacity as the Placement Resource for”: insert the name of the juvenile. The Placement
Resource in the receiving state must sign and date the form; witness must sign and date the form.
“Permission is hereby granted…”: insert name of state in which juvenile will reside and be supervised.
“Signature”: If the juvenile is on probation, the sending state’s JUDGE or court designee signs here. If the
juvenile is on parole, the sending state’s Interstate Compact for Juveniles official or designee signs here.
DHS-3040 (Rev. 3-12) Previous edition obsolete. MS Word
2
(Form IA)
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