Form DHS-4333 (ICPC-100B) "Interstate Compact Report on Child's Placement Status" - Michigan

What Is Form DHS-4333 (ICPC-100B)?

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 July 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-4333 (ICPC-100B) 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-4333 (ICPC-100B) "Interstate Compact Report on Child's Placement Status" - Michigan

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INTERSTATE COMPACT REPORT ON CHILD’S PLACEMENT STATUS
Department of Human Services
ICPC – 100B
TO:
FROM:
(Name and Address of Compact Administrator)
(Name and Address of Reporting ICPC Admin.)
IDENTIFYING INFORMATION
Child’s Name
Birth Date
Mother’s Name
Father’s Name
Name of Placement Resource
PLACEMENT STATUS
Date Withdrawn
Placement Request Withdrawn:
YES
NO
Placement Date
Initial Placement With: Name
Address
Type of Care
Placement Change:
Name
Date
Address
Type of Care
COMPACT TERMINATION
Reason:
Adoption Finalized
In Sending State
In Receiving State
Child Reached Majority / Legally Emancipated
Legal Custody and / or Guardianship Awarded and / or Returned to:
Name:
Relationship:
Treatment Completed
Sending State’s Jurisdiction Terminated
Child Returned to Sending State
Approved Resource Will Not Be Used For Placement
Other (Specify):
Date of Termination:
SIGNATURES
Person / Agency Supplying Information
Date
Reporting Compact Administrator or Alternate
Date
Department of Human Services (DHS) will not discriminate against any
AUTHORITY:
Public Act 114, 1984.
individual or group because of race, religion, age, national origin, color,
COMPLETION: Required.
height, weight, marital status, sex, sexual orientation, gender identity or
PENALTY:
Sending/Receiving Agency could lose
expression, political beliefs or disability. If you need help with reading, writing,
their license.
hearing, etc., under the Americans with Disabilities Act, you are invited to
make your needs known to a DHS office in your area.
DISTRIBUTION:
Complete four (4) copies of this form
Sending agency retains one (1) copy and forward three (3) copies to:
Sending Compact administrator retains one (1) copy and forwards two (2) copies to:
Receiving Compact Administrator retains one (1) copy, forwards one (1) copy to the receiving agency.
DHS-4333 (Rev. 7-09) Previous edition may be used. MS Word
INTERSTATE COMPACT REPORT ON CHILD’S PLACEMENT STATUS
Department of Human Services
ICPC – 100B
TO:
FROM:
(Name and Address of Compact Administrator)
(Name and Address of Reporting ICPC Admin.)
IDENTIFYING INFORMATION
Child’s Name
Birth Date
Mother’s Name
Father’s Name
Name of Placement Resource
PLACEMENT STATUS
Date Withdrawn
Placement Request Withdrawn:
YES
NO
Placement Date
Initial Placement With: Name
Address
Type of Care
Placement Change:
Name
Date
Address
Type of Care
COMPACT TERMINATION
Reason:
Adoption Finalized
In Sending State
In Receiving State
Child Reached Majority / Legally Emancipated
Legal Custody and / or Guardianship Awarded and / or Returned to:
Name:
Relationship:
Treatment Completed
Sending State’s Jurisdiction Terminated
Child Returned to Sending State
Approved Resource Will Not Be Used For Placement
Other (Specify):
Date of Termination:
SIGNATURES
Person / Agency Supplying Information
Date
Reporting Compact Administrator or Alternate
Date
Department of Human Services (DHS) will not discriminate against any
AUTHORITY:
Public Act 114, 1984.
individual or group because of race, religion, age, national origin, color,
COMPLETION: Required.
height, weight, marital status, sex, sexual orientation, gender identity or
PENALTY:
Sending/Receiving Agency could lose
expression, political beliefs or disability. If you need help with reading, writing,
their license.
hearing, etc., under the Americans with Disabilities Act, you are invited to
make your needs known to a DHS office in your area.
DISTRIBUTION:
Complete four (4) copies of this form
Sending agency retains one (1) copy and forward three (3) copies to:
Sending Compact administrator retains one (1) copy and forwards two (2) copies to:
Receiving Compact Administrator retains one (1) copy, forwards one (1) copy to the receiving agency.
DHS-4333 (Rev. 7-09) Previous edition may be used. MS Word