Form CFS490 (ICPC-100A) "Interstate Compact Placement Request" - Illinois

Form CFS490 or the "Form Cfs490 (icpc-100a) "interstate Compact Placement Request" - Illinois" is a form issued by the Illinois Department of Children and Family Services.

The form was last revised in October 1, 1999 and is available for digital filing. Download an up-to-date Form CFS490 in PDF-format down below or look it up on the Illinois Department of Children and Family Services Forms website.

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Download Form CFS490 (ICPC-100A) "Interstate Compact Placement Request" - Illinois

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CFS 490
STATE OF ILLINOIS
ICPC-100A
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
Rev. 10/99
INTERSTATE COMPACT PLACEMENT REQUEST
TO RECEIVING STATE:
FROM SENDING STATE:
ILLINOIS
SECTION I – IDENTIFYING DATA
NOTICE IS GIVEN OF INTENT TO PLACE:
Name of Child
DCFS I.D. #
Sex
Date of Birth
Ethnic Group
Name of Mother
Name of Father
(
)
-
Name of Agency or Person Responsible for Planning of Child
Telephone No.
Region/Site/Field
Address
(
)
-
Name of Agency, Person or Court Financially Responsible for Child
Telephone No.
Region/Site/Field
Address
SECTION II – PLACEMENT INFORMATION
(
)
-
Name of Person(s) or Facility Child Is To Be Placed With
Telephone No.
IL Provider I.D. #
Address
Type of Care:
Foster Family Care
Parent
Title IV-E Eligible
Yes
No
Group Home Care
Relative (not parent)
Subsidy/IV-E Assistance
Residential Treatment Center
Relationship:
Adoption:
Child Caring Institution
To be completed in:
Institutional Care Article (VI)
Other
Sending State
Legal Status:
Receiving State
Sending Agency Custody/Guardianship
Unaccompanied Refugee Minor
Adoption Assistance
Parent Relative Custody/Guardianship
Parental Rights Terminated – Right to Place for Adoption
Agreement (part C)
Court Jurisdiction Only
Other
SECTION III – SERVICES REQUESTED
Type of Study:
Supervisory Services:
Frequency of Supervisory Reports:
Parent Home Study
Request Receiving State to Arrange Supervision
Quarterly
Relative Home Study
Another Agency Agreed to Supervise
Semi-Annually
Adoptive Home Study
Sending Agency to Supervise
Upon Request
Foster Home Study/for reimbursement purposes
Other
Name and Address of Private Supervising Agency in Receiving State (if applicable)
Enclosed:
Child’s Social History
Court Order
Home Study of Placement Resources
Other Enclosures
Illinois Foster Care Study
Signature of Sending DCFS or Private Agency Staff Person or Court Official (MANDATORY)
Date
Signature of Illinois Interstate Compact Administrator or Alternate
Date
SECTION IV – ACTION BY RECEIVING STATE
Placement
Placement
Remarks
May Be Made
Shall Not Be Made
Signature of Receiving State Compact Administrator or Alternate
Date
DISTRIBUTION
Complete six (6) copies of this form for each child.
__ 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.
CFS 490
STATE OF ILLINOIS
ICPC-100A
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
Rev. 10/99
INTERSTATE COMPACT PLACEMENT REQUEST
TO RECEIVING STATE:
FROM SENDING STATE:
ILLINOIS
SECTION I – IDENTIFYING DATA
NOTICE IS GIVEN OF INTENT TO PLACE:
Name of Child
DCFS I.D. #
Sex
Date of Birth
Ethnic Group
Name of Mother
Name of Father
(
)
-
Name of Agency or Person Responsible for Planning of Child
Telephone No.
Region/Site/Field
Address
(
)
-
Name of Agency, Person or Court Financially Responsible for Child
Telephone No.
Region/Site/Field
Address
SECTION II – PLACEMENT INFORMATION
(
)
-
Name of Person(s) or Facility Child Is To Be Placed With
Telephone No.
IL Provider I.D. #
Address
Type of Care:
Foster Family Care
Parent
Title IV-E Eligible
Yes
No
Group Home Care
Relative (not parent)
Subsidy/IV-E Assistance
Residential Treatment Center
Relationship:
Adoption:
Child Caring Institution
To be completed in:
Institutional Care Article (VI)
Other
Sending State
Legal Status:
Receiving State
Sending Agency Custody/Guardianship
Unaccompanied Refugee Minor
Adoption Assistance
Parent Relative Custody/Guardianship
Parental Rights Terminated – Right to Place for Adoption
Agreement (part C)
Court Jurisdiction Only
Other
SECTION III – SERVICES REQUESTED
Type of Study:
Supervisory Services:
Frequency of Supervisory Reports:
Parent Home Study
Request Receiving State to Arrange Supervision
Quarterly
Relative Home Study
Another Agency Agreed to Supervise
Semi-Annually
Adoptive Home Study
Sending Agency to Supervise
Upon Request
Foster Home Study/for reimbursement purposes
Other
Name and Address of Private Supervising Agency in Receiving State (if applicable)
Enclosed:
Child’s Social History
Court Order
Home Study of Placement Resources
Other Enclosures
Illinois Foster Care Study
Signature of Sending DCFS or Private Agency Staff Person or Court Official (MANDATORY)
Date
Signature of Illinois Interstate Compact Administrator or Alternate
Date
SECTION IV – ACTION BY RECEIVING STATE
Placement
Placement
Remarks
May Be Made
Shall Not Be Made
Signature of Receiving State Compact Administrator or Alternate
Date
DISTRIBUTION
Complete six (6) copies of this form for each child.
__ 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.
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