MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN (ICPC) CHILD PLACEMENT STATUS REPORT
TO: (Name and Address of Receiving Compact Administrator)	FROM: (Name and Address of Sending ICPC Admin.)
SECTION I - IDENTIFYING INFORMATION: (One child per form)
Child’s Name	Date of Birth
Mother’s Name	Father’s Name
SECTION II - PLACEMENT STATUS:
Placement Request Withdrawn Date
Initial Placement With: Date Placement is to Occur:
Name	Address
Type of Care: Parent Foster Care Adoption
Relative Relative Foster Care Residential Care
Placement Change Date
Name	Address
Type of Care Parent Foster Care Adoption
Relative Relative Foster Care Residential Care
SECTION III – COMPACT TERMINATION:
Reason:
Adoption Finalized In Sending State In Receiving State (Include 3 copies of final decree)
Child Reached Age of Majority/Legally Emancipated
Legal Custody and/or Guardianship Awarded and/or Returned to: (Include 3 copies of court order)
Name	Relationship
Treatment Completed
Sending State’s Jurisdiction Terminated Unilaterally
Child Returned to Sending State
Approved Resource Will Not be Used For Placement
Other (Specify)
Date of Termination
Signature of Sending Agency or Person	Date Signed
Signature of Sending State Compact Administrator or Designee	Date Signed

PLEASE SUBMIT IN TRIPLICATE.