Form CFS490-1 (ICPC-100B) "Interstate Compact Report on Child's Placement Status" - Illinois

What Is Form CFS490-1 (ICPC-100B)?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 1999;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CFS490-1 (ICPC-100B) by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS490-1 (ICPC-100B) "Interstate Compact Report on Child's Placement Status" - Illinois

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STATE OF ILLINOIS
CFS 490-1
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
ICPC-100B
406 East Monroe Street
Rev. 9/99
Springfield, Illinois 62701-1498
INTERSTATE COMPACT REPORT ON CHILD’S PLACEMENT STATUS
(This form notifies Other State of placement or termination.)
TO RECEIVING STATE
FROM SENDING STATE
ILLINOIS
IDENTIFYING INFORMATION
Child’s Name
DCFS I.D. #
Birthdate
Mother’s Name
Father’s Name
PLACEMENT STATUS
Out of State
Departure Date
Name
Address
PAY:
Yes
No
IL Provider I.D. #
Type of Care
Placement Change
Date
Name
Address
*REASON FOR COMPACT TERMINATION
Approved Resource Will Not Be Used
Date of Termination
Placement Request Withdrawn
Ward Returned to Illinois
Date
Reached Majority/Legally Emancipated
Treatment Completed
Sending State’s jurisdiction Termination
Unilateral Dismissal (Without Receiving State’s Concurrence)
Guardianship Awarded To:
Name
Relationship
Subsidized
Yes
No
Court Order Attached
Yes
No
Adoption Finalized
In Sending State
In Receiving State
Adoption Assistance Agreement (Part C)
*Complete this section upon APPROVED closure ONLY
Signature of DCFS or Agency Staff Person Supplying Information
Date
Signature of Reporting compact Administrator or Alternate
Date
COMPLETE FOUR (4) COPIES OF THIS FORM.
SENDING AGENCY RETAINS ONE (1) COPY AND FORMS THREE (3) COPIES TO:
SENDING COMPACT ADMINISTRATOR RETAINS ONE (1) COPY AND FORWARDS TWO COPIES TO:
RECEIVING COMPACT ADMINISTRATOR RETAINS ONE (1) COPY AND FORWARDS ONE (1) COPY TO THE RECEIVING AGENCY.
STATE OF ILLINOIS
CFS 490-1
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
ICPC-100B
406 East Monroe Street
Rev. 9/99
Springfield, Illinois 62701-1498
INTERSTATE COMPACT REPORT ON CHILD’S PLACEMENT STATUS
(This form notifies Other State of placement or termination.)
TO RECEIVING STATE
FROM SENDING STATE
ILLINOIS
IDENTIFYING INFORMATION
Child’s Name
DCFS I.D. #
Birthdate
Mother’s Name
Father’s Name
PLACEMENT STATUS
Out of State
Departure Date
Name
Address
PAY:
Yes
No
IL Provider I.D. #
Type of Care
Placement Change
Date
Name
Address
*REASON FOR COMPACT TERMINATION
Approved Resource Will Not Be Used
Date of Termination
Placement Request Withdrawn
Ward Returned to Illinois
Date
Reached Majority/Legally Emancipated
Treatment Completed
Sending State’s jurisdiction Termination
Unilateral Dismissal (Without Receiving State’s Concurrence)
Guardianship Awarded To:
Name
Relationship
Subsidized
Yes
No
Court Order Attached
Yes
No
Adoption Finalized
In Sending State
In Receiving State
Adoption Assistance Agreement (Part C)
*Complete this section upon APPROVED closure ONLY
Signature of DCFS or Agency Staff Person Supplying Information
Date
Signature of Reporting compact Administrator or Alternate
Date
COMPLETE FOUR (4) COPIES OF THIS FORM.
SENDING AGENCY RETAINS ONE (1) COPY AND FORMS THREE (3) COPIES TO:
SENDING COMPACT ADMINISTRATOR RETAINS ONE (1) COPY AND FORWARDS TWO COPIES TO:
RECEIVING COMPACT ADMINISTRATOR RETAINS ONE (1) COPY AND FORWARDS ONE (1) COPY TO THE RECEIVING AGENCY.