MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Case Manager Statement to Court
IN THE	DIVISION
OF THE CIRCUIT COURT OF THE CITY/COUNTY OF
STATE OF MISSOURI
In re the Matter of	)
)	Case No
(“Child”)
(Date of Birth)
STATEMENT OF CASE MANAGER/POTENTIAL PLACEMENT/PARTY UNDER ICPC REGULATION 7 (Expedited)
Pursuant to the requirements of Regulation 7, Section 7(a) of the Interstate Compact on the Placement
of Children (ICPC), I	{full legal name}, certify
that the following information is true:
I have communicated directly with the potential placement resource,
[name of person with whom child to be placed}.
The potential placement resource is interested in being a placement resource for the child and is willing to cooperate with the ICPC process.
I have communicated directly with the potential placement resource,
[name of person with whom child to be placed}.
The potential placement resource is interested in being a placement resource for the child and is willing to cooperate with the ICPC process.
[name of person with whom child to be placed}.
father	grandparent	adult brother
mother	guardian	adult sister
stepparent	adult aunt	adult uncle
of
{name of child}.
The name, correct address, available telephone number or other contact information, date of birth, and social security number of the placement resource is as follows:
Name of placement resource:
Address of placement resource:
City/State/Zip Code:
Telephone numbers/contact information:
Date of birth:
Social Security Number:

In the Interest of
(child’s name)
Statement of Case Manager/Potential Placement/Party under ICPC Regulation 7
The name, correct address, available telephone number or other contact information, date of birth, and social security number of all adults in the home is as follows:
Adult 1 Name:
Address of placement resource:
City/State/Zip Code:
Telephone numbers/contact information:
Date of birth:
Social Security Number:
Adult 2 Name:
Address of placement resource:
City/State/Zip Code:
Telephone numbers/contact information:
Date of birth:
Social Security Number:
The number and type of rooms in the proposed residence is sufficient to accommodate the child as follows:
Number of bedrooms:
Number of other rooms in the home:
Number of adults residing in the home:
Number of children residing in the home, including child to be placed:
{name of person with whom child to be placed}
has or will access financial resources to feed, clothe, and care for the child.
If the child needs child care, it will we provide as follows:
N/A
{name of person with whom child to be placed}
acknowledges that a criminal records and child abuse history check will be completed on any persons residing in the home to be screened under the law of the receiving state and that, to the best knowledge of the placement resource, no one residing in the home has a criminal or child abuse history that would prohibit the placement.

In the Interest of
(child’s name)
Statement of Case Manager/Potential Placement/Party under ICPC Regulation 7
I am unaware of any fact that would prohibit the child being placed with the placement resource. Also, I have completed and am prepared to send all required paperwork to the sending state ICPC office, including the ICPC 100A and Form 101.
Dated:
(Signature)
(Titles)
(Printed Name)
(Address)
(City, State, Zip)
(Telephone Number)	(Fax Number)