MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN (ICPC) PLACEMENT REQUEST
TO (Name and Address of Compact Administrator in Receiving State)	FROM (Name and Address of Compact Administrator in Sending State)
SECTION I – IDENTIFYING DATA:
NOTICE IS GIVEN OF INTENT TO PLACE THIS CHILD (One child per form)
NAME OF CHILD	SEX	DATE OF BIRTH
ETHNIC GROUP White Black Hispanic American Indian/Alaskan Native Other
TITLE IV-E ELIGIBLE: Yes No Pending Unknown
NAME OF PARENT 1	NAME OF PARENT 2
NAME OF AGENCY OR PERSON RESPONSIBLE FOR PLANNING FOR THE CHILD	TELEPHONE NUMBER
ADDRESS
NAME OF AGENCY OR PERSON FINANCIALLY REPONSIBLE FOR THE CHILD	TELEPHONE NUMBER
ADDRESS
SECTION II – PLACEMENT INFORMATION:
NAME OF PERSON(S) OR FACILITY THE CHILD IS TO BE PLACED WITH	SSN (if available)
ADDRESS	TELEPHONE NUMBER
TYPE OF PLACEMENT SOUGHT ON THIS RESOURCE:	ADOPTION
PARENT FOSTER FAMILY CARE	SUBSIDY/IV-E ASSISTANCE AVAILABLE
RESIDENTIAL TREATMENT CENTER	ADOPTION TO BE COMPLETED IN:
RELATIVE (NOT PARENT) - RELATIONSHIP Maternal Paternal	SENDING STATE or
OTHER	RECEIVING STATE
LEGAL STATUS: SENDING AGENCY CUSTODY/GUARDIANSHIP COURT JURISDICTION ONLY
PARENT/RELATIVE CUSTODY/GUARDIANSHIP PARENTAL RIGHTS TERMINATED – RIGHT TO PLACE FOR ADOPTION
SECTION III – SERVICE REQUESTED:
INITIAL REPORT (IF APPLICABLE):	SUPERVISORY SERVICES:	SUPERVISORY REPORTS:
PARENT HOME STUDY RELATIVE HOME STUDY ADOPTIVE HOME STUDY FOSTER HOME STUDY	REQUEST RECEIVING AGENCY TO ARRANGE SUPERVISION ANOTHER AGENCY AGREED TO SUPERVISE SENDING AGENCY TO SUPERVISE	QUARTERLY SEMI-ANNUALLY MONTHLY
SUPERVISING AGENCY IN RECEIVING STATE:
NAME	ADDRESS
ENCLOSED:- CHILD’S SOCIAL HISTORY COURT ORDER HOME STUDY OF PLACEMENT RESOURCE
OTHER ENCLOSURES
SIGNATURE OF SENDING AGENCY OR PERSON	DATE SIGNED
SIGNATURE OF SENDING STATE COMPACT ADMINISTRATOR OR ALTERNATE	DATE SIGNED
SECTION IV – ACTION BY RECEIVING STATE:
PLACEMENT MAY BE MADE	REMARKS:
PLACEMENT SHALL NOT BE MADE
SIGNATURE OF RECEIVING STATE COMPACT ADMINISTRATOR OR ALTERNATE	DATE SIGNED