Form DHS-4332 (ICPC-100A) "Interstate Compact Placement Request" - Michigan

What Is Form DHS-4332 (ICPC-100A)?

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 May 1, 2009;
  • 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-4332 (ICPC-100A) 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-4332 (ICPC-100A) "Interstate Compact Placement Request" - Michigan

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INTERSTATE COMPACT PLACEMENT REQUEST
Department of Human Services
ICPC – 100A
FROM:
INTERSTATE SERVICES
TO:
(Name and Address of Compact Administrator in Receiving State)
CFS 235 S GRAND AVE STE 401
PO BOX 30037
LANSING, MI 48909
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 of Agency or Person Responsible for Planning for Child
Telephone Number
Address
Name of Agency or Person Financially Responsible for Child
Telephone Number
Address
Signature of Agency or Person Financially Responsible for Child (Court or Probate)
Date Signed
SECTION II – PLACEMENT INFORMATION
Name of Person(s) or Facility Child is to be Placed With
Telephone Number
Address
Residential Treatment Center
Relative (Not Parent) Relationship:
Adoption
TYPE OF CARE
IV-E (ADC-FC) Eligible
Child-caring Institution
To be completed in:
Institutional Care
Sending State
Yes
No
Foster Family Care
Article (VI)
Other:
Receiving State
Group Home Care
Parent
Subsidy
LE
GA
L STATUS
Sending Agency Legal Custody
Parental Rights Terminated
Parent/Relative Physical Custody
Unaccompanied Refugee Minor
Court Jurisdiction Only
Other:
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:
Name and Address of Supervising Agency in Receiving State
Child’s Social History
Court Order
ENCLOSED
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 or Receiving State Compact Administrator or Alternate
Date Signed
AUTHORITY:
Public Act 114, 1984.
Department of Human Services (DHS) will not discriminate against any individual or group
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
PENALTY:
Sending/Receiving Agency could lose
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make
their license.
your needs known to a DHS office in your area.
DISTRIBUTION – Complete six (6) copies of this form.
Sending Agency retains 1 copy and forwards 5 copies to:
Sending Compact Administrator retains 1 copy and forwards 4 copies to:
Receiving Agency Compact Administrator indicates action (Section IV) and forwards 1 copy to receiving agency and 2 copies to sending Compact Administrator within 30 days.
Sending Compact Administrator retains 1 completed copy and forwards the other completed copy to the Sending Agency.
DHS-4332 (Rev. 5-09) Previous edition obsolete. MS Word
INTERSTATE COMPACT PLACEMENT REQUEST
Department of Human Services
ICPC – 100A
FROM:
INTERSTATE SERVICES
TO:
(Name and Address of Compact Administrator in Receiving State)
CFS 235 S GRAND AVE STE 401
PO BOX 30037
LANSING, MI 48909
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 of Agency or Person Responsible for Planning for Child
Telephone Number
Address
Name of Agency or Person Financially Responsible for Child
Telephone Number
Address
Signature of Agency or Person Financially Responsible for Child (Court or Probate)
Date Signed
SECTION II – PLACEMENT INFORMATION
Name of Person(s) or Facility Child is to be Placed With
Telephone Number
Address
Residential Treatment Center
Relative (Not Parent) Relationship:
Adoption
TYPE OF CARE
IV-E (ADC-FC) Eligible
Child-caring Institution
To be completed in:
Institutional Care
Sending State
Yes
No
Foster Family Care
Article (VI)
Other:
Receiving State
Group Home Care
Parent
Subsidy
LE
GA
L STATUS
Sending Agency Legal Custody
Parental Rights Terminated
Parent/Relative Physical Custody
Unaccompanied Refugee Minor
Court Jurisdiction Only
Other:
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:
Name and Address of Supervising Agency in Receiving State
Child’s Social History
Court Order
ENCLOSED
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 or Receiving State Compact Administrator or Alternate
Date Signed
AUTHORITY:
Public Act 114, 1984.
Department of Human Services (DHS) will not discriminate against any individual or group
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
PENALTY:
Sending/Receiving Agency could lose
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make
their license.
your needs known to a DHS office in your area.
DISTRIBUTION – Complete six (6) copies of this form.
Sending Agency retains 1 copy and forwards 5 copies to:
Sending Compact Administrator retains 1 copy and forwards 4 copies to:
Receiving Agency Compact Administrator indicates action (Section IV) and forwards 1 copy to receiving agency and 2 copies to sending Compact Administrator within 30 days.
Sending Compact Administrator retains 1 completed copy and forwards the other completed copy to the Sending Agency.
DHS-4332 (Rev. 5-09) Previous edition obsolete. MS Word