Form PPS9130 "Interstate Compact Placement Request" - Kansas

What Is Form PPS9130?

This is a legal form that was released by the Kansas Department for Children and Families - a government authority operating within Kansas. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the Kansas Department for Children and Families;
  • 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 PPS9130 by clicking the link below or browse more documents and templates provided by the Kansas Department for Children and Families.

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Download Form PPS9130 "Interstate Compact Placement Request" - Kansas

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State of Kansas
PPS 9130
One form per child
Department for Children and Families
REV. 7/2012
Please type
Prevention and Protection Services
(ICPC 100A)
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN REQUEST
TO:
FROM:
SECTION I - IDENTIFYING DATA
Notice is given of intent to place - Name of Child:
Ethnicity: Hispanic Origin:
Yes
No
Unable to determine/unknown
Social Security Number:
ICWA Eligible:
Race:
American Indian or
Native Hawaiian/ Other
Yes
No
Alaskan Native
Pacific Islander
Asian
Black or African American
Sex:
Date of Birth
Title IV-E determination
White
Yes
No
Pending
Name of Mother:
Name of Father:
Name of Agency or Person Responsible for Planning for Child:
Phone:
Address:
Name of Agency or Person Financially Responsible for Child:
Phone:
Address:
SECTION II - PLACEMENT INFORMATION
Name of Person(s) or Facility Child is to be placed with:
Soc Sec # (optional):
Soc Sec # (optional):
Address:
Phone:
Type of Care Requested:
Parent
ADOPTION
Relative (Not Parent)
IV-E Subsidy
Foster Family Home
Residential Treatment Center
Relationship: _______________
Non IV-E Subsidy
Group Home Care
Institutional Care-Article VI,
__________________________
To Be Finalized In:
Child Caring Institution
Adjudicated Delinquent
Other:
Sending State
Receiving State
__________________________
Current Legal Status of Child:
Protective Supervision
Sending Agency Custody/Guardianship
Parental Rights Terminated-Right to Place for Adoption
Parent Relative Custody/Guardianship
Unaccompanied Refugee Minor
Court Jurisdiction Only
Other:
SECTION III - SERVICES REQUESTED
Initial Report Requested (if applicable):
Supervisory Services Requested:
Supervisory Reports Requested:
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
Other:
Name and Address of Supervising Agency in Receiving State:
Enclosed:
Child's Social History
Court Order
Financial/Medical Plan
Other Enclosures
Home Study of Placement Resource
ICWA Enclosure
IV-E Eligibility Documentation
Signature of Sending Agency or Person:
Date:
Signature of Sending State Compact Administrator, Deputy or Alternate:
Date:
SECTION IV - ACTION BY RECEIVING STATE PURSUANT TO ARTICLE III(d) of ICPC
Placement shall not be made
Placement may be made
REMARKS:
Signature of Receiving State Compact Administrator, Deputy or Alternate:
Date:
(This form supersedes CFS 4013REV 7/2011)
State of Kansas
PPS 9130
One form per child
Department for Children and Families
REV. 7/2012
Please type
Prevention and Protection Services
(ICPC 100A)
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN REQUEST
TO:
FROM:
SECTION I - IDENTIFYING DATA
Notice is given of intent to place - Name of Child:
Ethnicity: Hispanic Origin:
Yes
No
Unable to determine/unknown
Social Security Number:
ICWA Eligible:
Race:
American Indian or
Native Hawaiian/ Other
Yes
No
Alaskan Native
Pacific Islander
Asian
Black or African American
Sex:
Date of Birth
Title IV-E determination
White
Yes
No
Pending
Name of Mother:
Name of Father:
Name of Agency or Person Responsible for Planning for Child:
Phone:
Address:
Name of Agency or Person Financially Responsible for Child:
Phone:
Address:
SECTION II - PLACEMENT INFORMATION
Name of Person(s) or Facility Child is to be placed with:
Soc Sec # (optional):
Soc Sec # (optional):
Address:
Phone:
Type of Care Requested:
Parent
ADOPTION
Relative (Not Parent)
IV-E Subsidy
Foster Family Home
Residential Treatment Center
Relationship: _______________
Non IV-E Subsidy
Group Home Care
Institutional Care-Article VI,
__________________________
To Be Finalized In:
Child Caring Institution
Adjudicated Delinquent
Other:
Sending State
Receiving State
__________________________
Current Legal Status of Child:
Protective Supervision
Sending Agency Custody/Guardianship
Parental Rights Terminated-Right to Place for Adoption
Parent Relative Custody/Guardianship
Unaccompanied Refugee Minor
Court Jurisdiction Only
Other:
SECTION III - SERVICES REQUESTED
Initial Report Requested (if applicable):
Supervisory Services Requested:
Supervisory Reports Requested:
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
Other:
Name and Address of Supervising Agency in Receiving State:
Enclosed:
Child's Social History
Court Order
Financial/Medical Plan
Other Enclosures
Home Study of Placement Resource
ICWA Enclosure
IV-E Eligibility Documentation
Signature of Sending Agency or Person:
Date:
Signature of Sending State Compact Administrator, Deputy or Alternate:
Date:
SECTION IV - ACTION BY RECEIVING STATE PURSUANT TO ARTICLE III(d) of ICPC
Placement shall not be made
Placement may be made
REMARKS:
Signature of Receiving State Compact Administrator, Deputy or Alternate:
Date:
(This form supersedes CFS 4013REV 7/2011)