ࡱ                >  	               i          k          h    	               :   bjbj                  	 8L      #      <                                                                                                                              8   ?  L              i%                                 _     !  t     <   $     $      $      $      $      $      $      '    )  d   $  Q                                                      ^               $                                          
  #%                            X                           $                                                                           $                           #                                                                             $                 yW                X   #             $     9%  0   i%      #  ,   *      o    *     $                                                                              *                    $          U  ^            L                                                          $      $                                                                                              i%                                                                                                                  *                                                                                                                      	    :     	                                                                                                                                                                                                                                                                                                                                                                                                                                      MISSOURI DEPARTMENT OF SOCIAL SERVICESCHILDRENS DIVISIONCHILD CUSTODY VERIFICATION-ICPCInstructions:  When there is a disruption in a resource home related to an Interstate Compact for the Placement of Children (ICPC) placement, the Children's Division (CD) Case Manager completes this form, as timely as possible, and it is reviewed and approved by the case manager's immediate supervisor.  This form, along with necessary documentation, is then immediately to be faxed to CD central office ICPC staff at  ( 5 7 3 )   5 2 2 - 8 4 4 3 .   R e s o u r c e   H o m e   N a m e :         F O R M T E X T              D V N :         F O R M T E X T              A d d r e s s :     F O R M T E X T               F O R M T E X T             T e l e p h o n e   N u m b e r :     F O R M T E X T               C h i l d ( r e n ) )     ( P l e a s e   u s e   a   s e p a r a t e   s h e e t   i f   n e c e s s a r y . )   N a m e :   1 .    D a t e   o f   B i r t h :    D C N :     2 .         3 .       4 .     S u m m a r y     ( P l e a s e   u s e   a   s e p a r a t e   s h e e t   i f   n e c e s s a r y . )    D a t e   a n d   b r i e f   s u m m a r y   o f   t h e   c i r c u m s t a n c e s   s u r r o u n d i n g   t h e   r e s o u r c e   h o m e   d i s r u p t i o n :        F O R M T E X T                     L e g a l   S t a t u s   o f   t h e   c h i l d ( r e n ) :   A   j u v e n i l e officer, law enforcement, or a physician has taken emergency protective custody of the child(ren) pursuant to 210.125 RSMo and Supreme Court Rules 111.01 and 111.11  If yes, include a copy of Form CS-33, Authorization to Provide Alternative Care.                               FORMCHECKBOX  Yes               FORMCHECKBOX NoA juvenile officer has petitioned the court for custody of the child(ren) pursuant to 211.031 RSMo.  If yes, include a copy of the petition to the court.                                 FORMCHECKBOX  Yes               FORMCHECKBOX NoA Missouri court order has been issued with regard to custody of the child(ren) pursuant to 211.031 RSMo.  If yes, include a copy of the Missouri court order.                  FORMCHECKBOX   Yes              FORMCHECKBOX NoNote:  In the event that there is more than one (1) court order in effect, for example, a court order from another state and one from a Missouri court, or the child(ren) has been taken into emergency protective custody or a juvenile officer has filed a petition with the court, the respective courts will need to communicate with each other to resolve the legal conflict.  CD staff is to immediately enlist the help of the Division of Legal Services (DLS) to assist with the legal aspects of the case.  Staff must obey                                                                                                                                                                                                                         =  W  \  ]  ^  }    	  	  	   
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        @        	    (                        *                                                    4 
l af4p(                        yt=d                  $  &  (                                                                                                                                                                                                                                                                                   $7$ 8$ H$ If   gd' O  kd&  $$If   l 4 L0**        	  
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         ytt  
            &  (  *  8  :  H  J  T  V          r  t                  ܼܼܼܓq]S                      h CJ ^J aJ  &j    hJUC CJ U^J aJ mH nH u 'j*  hX h._` CJ U^J aJ j    hX CJ U^J aJ hX CJ ^J aJ  !hX hl B*CJ ^J aJ ph hX B*CJ ^J aJ ph h`$ h._` 5>*CJ ^J aJ  h`$ ht 5>*CJ ^J aJ  h._` CJ ^J aJ  ht CJ ^J aJ  h`$ hl 5>*CJ ^J aJ (  *  4  6  8  t            f            f            f                                                                                                                                                   $7$ 8$ H$ If   gd'   kd'  $$If   l 4ZF L0*L        L        L        	                     *                                        4 
l af4p                  yt._`  8  :  @  B  D  F  H  t            f            f            f            f            f                                                                                                                 $7$ 8$ H$ If   gd'   kd'  $$If   l 4pF L0*L        L        L        	                     *                                        4 
l af4p                  yt._`  H  J  P  R  T  t            f            f            f                                                                                                                                                   $7$ 8$ H$ If   gd'   kd(  $$If   l 4LF L0*L        L        L        	                     *                                        4 
l af4p                  yt._`  T  V    t            f                                                                                                                                                                                     $7$ 8$ H$ If   gd'   kd~)  $$If   l 4F L0*L        L        L        	                     *                                        4 
l af4p                  yt._`                                                                                                                                                                                                                                                                                                      $7$ 8$ H$ If   gd' O  kdK*  $$If   l 4  L0**        	  
         *                4 
l af4p
         ytX          M  N                          S            >                                                             
& F  h $7$ 8$ H$ If   gd._` O  kd+  $$If   l 4P  L0**        	  
         *                4 
l af4p
         ytX    $7$ 8$ H$ If   gd' O  kdR+  $$If   l 4 L0**        	 
      *                4 
l af4p
      yt._`                          %  &  '  9  :  H  I  J  L  M  N  Z            ξraT                        h._` hX CJ ^J aJ  !j,  hJUC CJ U^J aJ !jt,  hJUC CJ U^J aJ j    h._` CJ U^J aJ h._` 5CJ ^J aJ h` hX 5CJ ^J aJ hX CJ ^J aJ  h._` CJ ^J aJ  h`$ hl 5>*CJ ^J aJ  !hX h` B*CJ ^J aJ ph !hX hl B*CJ ^J aJ ph h`$ hX 5>*CJ ^J aJ       *  +  9  :  ;  =  >  ?                       !  "  $  %  &    ,   8  8  ָևv֣f\NLN   Uh/ h` 5CJ ^J aJ h` CJ ^J aJ  h`$ hX 5>*CJ ^J aJ  !j.  hJUC CJ U^J aJ !jD.  hJUC CJ U^J aJ h._` 5CJ ^J aJ hX CJ ^J aJ  hX 5CJ ^J aJ h._` hX CJ ^J aJ  !j-  hJUC CJ U^J aJ h._` CJ ^J aJ  j    h._` CJ U^J aJ !j\-  hJUC CJ U^J aJ  N  >  ?  %  &  8                                                  o                                                                                                                                                    $$7$ 8$ H$ If   a$gd O  kd,/  $$If   l 4 L0**        	 
      *                4 
l af4p
      yt`   
& F $7$ 8$ H$ If   gd'    $7$ 8$ H$ If   gd'   
& F $7$ 8$ H$ If   gd._`   the Missouri court order while the legal status of the case is being decided.  This includes honoring the Missouri court's jurisdiction when emergency protective custody has been taken or the juvenile officer has petitioned the Missouri court.My responses to the above legal status of the child(ren) statements are correct, to the best of my knowledge.Signature of CD Case Manager          DateSignature of Immediate Supervisor        Date FORMTEXT                                                           F O R M T E X T               	 	 	 	 	 	                    M O ( x x x - x x x x )   C D - I C P C - 4   ( 0 7 / 2 0 0 9 )                                                                                                                                                                                                                                                                                                                                      8  8  8  9  49  E9  F9  b9  d9  e9  9  9  9  9  9  9  9  9  9  9  9  9  9  9  9  pfXN                                hX CJ ^J aJ  j    hX CJ U^J aJ h/Nb CJ ^J aJ  h`$ h/Nb 5>*CJ ^J aJ  h._` B*CJ ^J aJ ph !h._` h/Nb B*CJ ^J aJ ph !h._` hX B*CJ ^J aJ ph h`$ hJ 5>*CJ ^J aJ  hJ CJ ^J aJ  h._` hX 5CJ ^J aJ h._` hJ 5CJ ^J aJ h`$ h` 5>*CJ ^J aJ  h` CJ ^J aJ 8  8  d9  e9  9  9  9  9                          S                        M            D            D                         	  $If   gdX   $If   O  kdN0  $$If   l 4 L0**            	 
      *                4 
l af4p
      yt._`    $7$ 8$ H$ If   gd' O  kd/  $$If   l 4 L0**            	 
      *                4 
l af4p
      yt`  9  9  9  9  9  :  :                          H                        6                              $7$ 8$ H$ If   ^ gd/Nb   kd0  $$If   l 4\ L!0*                        p        	        (                                    *                                                    4 
l af4p(                                    yt._`    $7$ 8$ H$ If   gd'  9  9   :  
:  :  :  :  &:  (:  *:  4:  6:  8:  ::  >:  J:  L:  N:  R:  T:  X:  Z:  ^:  `:  d:  f:  j:  l:  p:  :  :  :  ݿݵݿ}y}y}y}ykgkg\Q\   h"z hV CJ aJ  h"z hoPx CJ aJ  hoPx  j    hoPx UmH nH u h"z  j    h"z Uh	9  hX  h/Nb  h`$ h/Nb 5>*CJ ^J aJ  'jz2  hX h._` CJ U^J aJ hX CJ ^J aJ  h/Nb CJ ^J aJ  &j    hJUC CJ U^J aJ mH nH u j    hX CJ U^J aJ 'j1  hX h._` CJ U^J aJ  :  8:  ::  <:  >:  L:  P:              D            B            B            B            =                              gd      kd 3  $$If   l 4 \ L!0*                        p        	    (                        *                                                    4 
l af4p(                        yt._`     $7$ 8$ H$ If   ^ gd/Nb  P:  R:  V:  X:  \:  ^:  b:  d:  h:  j:  n:  p:  :  :  :                                                                                                                                                                                                                                                                                                                                                          $$If   a$gd"z l                 $If   l                   gd     :  :  :  :  :  :  :  :                                                                                                                                                                                                                                                                                                                                                                                           h	9  h"z  j    hoPx UmH nH u hoPx  h"z hoPx CJ aJ  h"z h=d CJ aJ :  :  :  :  :  :  :  :                                                                                                                                                                                                                                                                      g  kd4  $$If   l F D* X                 X                 X                
t    6                                      4   4 
l a  yt"z  6 &P 1h:pQ= / =!"#$%                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Z!  D d n n   
            ((                                 B   
      
  S    A                      b    "UJE"jq       D       n   "UJE"jqPNG

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looaj.>`ܠ2DD>w 5u&uD~31ry@O
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 ZZKaE牤\94Y1<CcvMWW1{:;Qip,\ky*cgg6	mJN=.[&YcDDdM&D_CSRl5uF>i<9Ԟ6?wwy2Lv;rY5A\M#Z,t^&bx[|d+QST8aa֐ҸCmjDM$2"(S|67C0\Q-igd+ܽl1$r5>&ׅ+ݘn.zxZ>9:&9VB!}#Dm=FQf]dلů\!Bi=kxC ;#UY$]4I?^ޢw/U674:.F<y"[@~叝i@fj'oL7vI!9>2y<j5fswJձdȧzkL}Ն=bjA7]Jo=iơm{ec<&H\ۀOt5}	]DRȢkon6LM3ZB۠&ɪjمAD=eZHi.fHvTB,n[:z.4B2+:XiT:|5mjAY8u3Mpi8uE{ڋ~Q[i bLuZT,}Z;C}]!5E<MY/'3KW??y9_>̆&bhsGoIgR{ukt_V9^70fGV# XMv:~ZOک{a_hST",Gh$p.t~]V2	CFT^u;HU[eGڮ]rי3kx'I  $9ZԛOqI<dtο.d5=ٚoQ#--d5K~kFpM48)-n }&|~`'|n9G*jRqԙkn̶vgP4.(Qf~)8t7>mYpo;@DPc~^hҳ#)4K㣠W\y&!k$'+eT0>-kA@YJe	)T{ (=dmby]猲AuzpyvϣF[OXA&qsƬl`&a^W0;( )@'M$M*3yNY9TI\g*;_|5a,K>:!rxUSwNwSdGW`^e&Lu쪖I_]0Qצ2rCc-{Da *W*A$}폍46ufzcޡ)L{(.iL4p<d_eEyƂ	3S>A|"G7
Ad GQe/HN.W*+	z{ox9C	pz3H9S%@+gɱj1J^MB"S5)X/9xubΫ':R:B5F@&?
S1eJE`,}=p\rY[Z_ty$sI_ueeؔ<($S#b%<K'#5P,)syO|@hLYYk1nGϪTתXOшg3GKlؤǌ>hZ$`&SsXfʶM;
#rG??R_cC0ɌG*L&:(_j4ʊS2%հLii}irb>ҔڗcGM`lX=`jj,[ 1&>R<钷V* RRJ++38AWm|7_mnL-/+;3LɔM);PQ>%eʔjVV [.c.KƧzm'0**A0R5>0;T9OrIX=}cط՗#iŉd    IENDB` $$If   !v h5 85&#v 8#v&:V l 4?	              *  , 5 85&4    af4p            ytQ=  $$If   !v h5 *#v *:V l 4S	 
      *  , 5 */      4    af4p
      yt  $$If   !v h5 *#v *:V l 4 	  
         *  , 5 */      4    af4p
         yt t   D                                                                      T e x t 2                           t   D                                                                    T e x t 1                           t   D                                                                      T e x t 3                           v   D                                                                     T e x t 2 3                           t   D                                                                
    T e x t 4                           $$If   !v h5 L5&52
5@#v L#v&#v2
#v@:V l 4	    (                        *  , 5 L5&52
5@/      4    af4p(                        yt=d  $$If   !v h5 *#v *:V l 4	  
         *  , 5 */      4    af4p
         ytt  $$If   !v h5 L5L5L#v L:V l 4Z	                     *  , 5 L/      4    af4p                  yt._`  $$If   !v h5 L5L5L#v L:V l 4p	                     *  , 5 L/      4    af4p                  yt._`  $$If   !v h5 L5L5L#v L:V l 4L	                     *  , 5 L/      4    af4p                  yt._`  $$If   !v h5 L5L5L#v L:V l 4	                     *  , 5 L/      4    af4p                  yt._`  $$If   !v h5 *#v *:V l 4 	  
         *  , 5 */      4    af4p
         ytX v   D                                                                    T e x t 2 0                            $$If   !v h5 *#v *:V l 4	 
      *  , 5 */      4    af4p
      yt._`  $$If   !v h5 *#v *:V l 4P 	  
         *  , 5 */      4    af4p
         ytX t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                          $$If   !v h5 *#v *:V l 4	 
      *  , 5 */      4    af4p
      yt`  $$If   !v h5 *#v *:V l 4	 
      *  , 5 */      4    af4p
      yt`  $$If   !v h5 *#v *:V l 4	 
      *  , 5 */      4    af4p
      yt._` $$If   !v h5 555p#v #v#v#vp:V l 4	        (                                    *  , 5 555p/      4    af4p(                                    yt._`    D                                                                     T e x t 2 1        M / d / y y y y                      D                                                                     T e x t 2 2        M / d / y y y y                   $$If   !v h5 555p#v #v#v#vp:V l 4 	    (                        *  , 5 555p/      4    af4p(                        yt._` X $$If     !v h5 X5X5X#v X:V l 
t    65 Xyt"z                                                                                                                                                                                                                                                                                                                                                                                                                  ^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2                     0  @  P  `  p                   2  (         0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p      8  X        V  ~     _HmH	nH	sH	tH	    R  ` R   '    N o r m a l      ) B*CJ OJ QJ _HaJ mH	ph    sH	tH	                   D A  D          D e f a u l t   P a r a g r a p h   F o n t     R i@ R          T a b l e   N o r m a l      4 
l 4   a      ( k  (           N o   L i s t         4 @  4   Q=    H e a d e r      !   4  @ 4   Q=    F o o t e r      !   j @ j   Q=   
 T a b l e   G r i d   7 :V 0                                   H   "H   OL    B a l l o o n   T e x t      CJ OJ QJ ^J aJ PK     !         [Content_Types].xmlj0Eжr(΢Iw},-j4	wP-t#bΙ{UTU^hd}㨫)*1P'	^W0)T9<l#$yi};~@(Hu*Dנz/0ǰ$X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?   PK     ! ֧   6     _rels/.relsj0}Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/Seе   PK     ! ky         theme/theme/themeManager.xmlM
 @}w7c(Ebˮ CAǠҟ7՛KY,e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8   PK     !   P     theme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$!)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu	gZo~ٺlAplxpT0+[}`jzA V2Fi@qv֬5\|ʜ̭NleXdsjcs7fW+Ն7`gȘJj|h(KD- dXiJ؇(x$(:;˹!I_TS1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ
x}rxwr:\TZaG*y8IjbRc|XŻǿI
u3KGnD1NIBs
RuK>V.EL+M2#'fi~Vvl{u8zH
*:(W☕~JTe\O*tHGHY }KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4=3ڗP
1Pm\\9Mؓ2aD];Yt\[x]}Wr|]g-
eW)6-rCSjid	DЇAΜIqbJ#x꺃6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8քAV^fHn-"d>znǊ	ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ ;%1U٥m;R>QDDcpU'&LE/pm%]8firS4d7y\`JnίIR3U~7+׸#mqBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D	vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCMm<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍ    PK     ! ѐ     '   theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э56?$Q,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/]QAsم(#L[    PK-      !                       [Content_Types].xmlPK-      ! ֧   6               +  _rels/.relsPK-      ! ky                     theme/theme/themeManager.xmlPK-      !   P                 theme/theme/theme1.xmlPK-      ! ѐ     '             	  theme/theme/_rels/themeManager.xml.relsPK      ]  
    <?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>    `    L                 	                  8   ;   ;   >      B
          8  9  :  :  
                     !   $      "
  ~
  l    (  8  H  T      N  8  9  :  P:  :  :                                             "   #   %   )  5  ;  F  R  X  e  q  w  y                    &  9  I      *  :        !  
  
          `  FFFFTFFG$G$G$G$G$G$FF  @                                @                            0    (    	                    
          B    
        S              	   ?                          (    	                    
             
      
         ;            @3f         4       D R A F T   A r i a l   P o w e r P l u s W a t e r M a r k O b j e c t 1   c "$                    ?                       
      
         ;            @3f         4       D R A F T   A r i a l   P o w e r P l u s W a t e r M a r k O b j e c t 2   c "$                    ?                        
      
         ;            @3f         4       D R A F T   A r i a l   P o w e r P l u s W a t e r M a r k O b j e c t 3   c "$                    ?                   `        8   >             |*    t       X"  t               |*    t         T e x t 2  T e x t 1  T e x t 3  T e x t 2 3  T e x t 4  T e x t 2 0  C h e c k 1  C h e c k 2  C h e c k 3  C h e c k 4  C h e c k 5  C h e c k 6  T e x t 2 1  T e x t 2 2 )  F  e  z        :    +      
    a                              	   
            <  Y  x        '  J    ;    "      a  	    \  t8#  ]  s$  ^  
 _  D[$  `  \$  a  A$  b  ,$  c  t]$  d  ŉA  A      1	  1	  	  
  
  a                                       I  I      9	  9	  	  
  
  a                                 9   	   *urn:schemas-microsoft-com:office:smarttagsState 9      *urn:schemas-microsoft-com:office:smarttagsplace   H:#     	               	          	     	          	         #  #  %  %  &  &  (  )  +  ,  .  /  ^  a                    #  #  %  %  &  &  (  )  +  ,  .  /  ^  a                            )  <  F  Y  e  x  y                          +  a  a                  %  &  H  I      9  :         !  
            "  #  #  %  %  &  &  (  )  +  ,  .  A  C  W  Y  [  ^  a                                                                                     %  &  H  I      9  :         !  "  #  #  %  %  &  &  (  )  +  ,  .  /  D  E  J  V  a                                     ^ZjNm              h         ^`OJ QJ o( h    H                h         ^`OJ QJ ^J o( h    H   o              h        p p^p`OJ QJ o( h    H                h        @ @^@`OJ QJ o( h    H                h         ^`OJ QJ ^J o( h    H   o              h         ^`OJ QJ o( h    H                h         ^`OJ QJ o( h    H                h         ^`OJ QJ ^J o( h    H   o              h        P P^P`OJ QJ o( h    H      ^Z                      	 	 	 	 	 	 	 	 	#                "    Q= t ` N& / <?7 JUC OL M V X *Z ._` sa /Nb iq 0r oPx }  "z ' 	9 Gm : W l y p =d J \ 6      #  %         @L                ,	  
  `  X   @  X  
    X      X   @  X  p @  X  :        U n k n o w n                                   G  *                  T i m e s   N e w   R o m a n   5                       S y m b o l   3.  *                  A r i a l   5.  * a               T a h o m a   ?=  	*                  C o u r i e r   N e w   ;                                W i n g d i n g s   A                         C a m b r i a   M a t h   "  1 h  h    FFF      z	            z	         r!                                                                                                                                                                                                                                                                                                                           4    d                                                                               2Q                           HP    	?    6    2                     !                             x   x                              h i l l 9 s i  S t e p h a n i e   L .   R o e t t g e n                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Oh +'0                                                       	   (     4  
   T     `     l     x                                                     hill9si                            Form Shell Missouri Seal.dot          Stephanie L. Roettgen         2         Microsoft Office 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                                                                      !   "   #   $   %   &   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   Y   Z   [   \   ]   ^   _   a   b   c   d   e   f   g   j   R o o t   E n t r y                                                 	           F            Wl          D a t a                                                         
                                     '   o4      1 T a b l e                                                                                                B   )*      W o r d D o c u m e n t                                                                                        8L       S u m m a r y I n f o r m a t i o n                           (                                     X           D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        `           C o m p O b j                                                                                           y                                                                                                                               
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