Forms Appendix 619-01-30
SFN 966, (ICPC 100-B), Interstate Compact Report on the Placement/Replacement Status of Child 619-01-30-05
(Revised 1/1/25 ML 3865)
PURPOSE: To confirm that a placement in accordance with the Compact has been made, to indicate changes in placement, and to confirm the termination of the placement.
INSTRUCTIONS FOR COMPLETION: In the first two blocks, enter the name of the sending and receiving state.
Section 1: Identifying Information
Enter the full legal name and birthdate of the child for whom this placement information is being reported.
Section 2: Placement Status
If you have submitted SFN 965, 100A, to request placement approval and have decided not to explore that resource further, mark the box for Placement Request Withdrawn and the date of your decision.
This item will be used only when no action has yet been taken on SFN 965, 100A. If you are withdrawing more than one request, submit separate ICPC 100-Bs on each and list each respective Placement Resource in that space under INDENTIFYING INFORMATION.
To confirm the Initial Placement, mark the next box and indicate the resource’s name and address and the exact date of placement. For Type of Care, enter the same information that is marked for that item on SFN 965, 100A: Foster Family Care, Adoption, etc., with relative placements, specify the relationship.
If some aspect of the placement changes while the child remains in the receiving state, mark the Placement Change box and indicate the exact date of the change, i.e. mother remarries and/or moves to a new address, a termination of parental rights has occurred, so the placement type changes from foster care to adoption. If the child remains in the receiving state and the level of care changes, a new SFN 965, 100A, will be required. Contact the Compact Administrator at the state office for directions.
Section 3: Compact Termination
Adoption Finalization:If an ICPC adoptive placement has been finalized, mark the box and the appropriate box for the sate in which finalization occurred, Sending or Receiving.
Child Reached Aged Majority/Legally Emancipated: (Age of majority in sending state.) Mark this box if the child has reached age 18 and has simultaneously ceased to be the responsibility of the sending agency or if the child has become emancipated through such legal action as marriage or court decision.
Legal Custody and/or Guardianship Awarded or Returned to: This item is to be marked when final custody of guardianship (wording varies among states) has been disposed of with the concurrence of the receiving state. Indicate the Name and Relationship of the person(s) to whom this applies.
Sending State's Jurisdiction Terminated: This item is marked when the jurisdiction of the sending state has ended for some reason other than that which relates to the third category (Legal Custody…); for example, if formal legal custody/guardianship is not going to be addressed but both states agree that supervision is no longer required or if both states agree to transfer jurisdiction to the receiving state. If the sending state’s jurisdiction is terminated without the concurrence of the receiving state (including custody/guardianship transfer), the decision was made unilaterally, and that box should be marked as well.
Child Returned to Sending State: If the child was returned to the sending state (placement disrupted or was intended to be temporary), mark this box.
Approved Resource Will Not Be Used for Placement: This box should be marked when you have received an approved ICPC-100A (SFN 965) but have decided not to place the child with that resource.
