Interstate Compact of the Placement of Children Handout and Forms

North Carolina Information | ICPC State Pages
1 of 3
http://icpcstatepages.org/northcarolina/info/
Office Hours: Monday-Friday, 8:00 a.m. to 5:00 p.m. Eastern. · Phone: August 2013 Effective Date for All Information (919) 527-6390. · Fax: Contact
ICPC Administrative Assistant to Verify Mailing Address and Faxing.
North Carolina Consultants/Specialists
Compact Administrators
Compact Administrator
Deputy Compact Administrator
Kevin Kelley
Carla McNeill
820 S. Boylan Avenue
820 S. Boylan Avenue
McBryde Building East
McBryde Building East
Mail Service Center 2409
Mail Service Center 2409
Raleigh, NC 27603-2409
Raleigh, NC 27603-2409
(919) 527-6391
[email protected]
(919) 527-6391
Consultants
ICPC Specialist
Administrative Assistant
Charlene Timmons
Luvenia Roberts
[email protected]
[email protected]
(919) 527-6395
(919) 527-6390
ICPC Specialist
Administrative Assistant
Lakecia Knight
Chloe Smith
[email protected]
[email protected]
(919) 527-6397
(919) 527-6390
Sherita Wright
[email protected]
(919) 527-6394
ICPC Specialist
Debra McHenry
International Adoptions
No information provided
[email protected]
(919) 527-6396
Rebekah Nelson
[email protected]
(919) 527-6398
Mailing Address
Regular Mailing Address
Federal Express Address
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North Carolina Information | ICPC State Pages
2 of 3
http://icpcstatepages.org/northcarolina/info/
North Carolina ICPC Unit
North Carolina ICPC Unit
820 S. Boylan Avenue
820 S. Boylan Avenue
McBryde Building East 1st Floor
McBryde Building East 1st Floor
Mail Service Center 2409
Raleigh, NC 27603
Raleigh, NC 27603-2409
(Courier direction: Smithwick & Richardson Ave)
Useful Telephone Numbers
Child Abuse Hotline
No information provided
Juvenile Compact Office (ICJ)
Traci P. Marchand
(919) 743-8126
[email protected]
Mental Health Compact Office
No information provided
Adoption and Medical Assistance Compact Office (ICAMA)
Amelia Lance
820 S. Boylan Avenue
McBryde Building East
Mail Service Center 2408
Raleigh, NC 27603-2408
(919) 527-6346 ICAMA only
[email protected]
International Adoptions
No information provided
Useful Websites
Interstate Compact on the Placement of Children (ICPC)
Interstate Compact on Adoption and Medical Assistance (ICAMA)
Interstate Compact for Juveniles (ICJ)
Statutory Codes
State ICPC Code:
7B-3800
Age of Majority and Code:
18 years
7B-3800
Statutory Penalties Under ICPC:
7B-3800
Co-Located Compacts - ICPC, ICAMA, ICJ
ICPC/ ICJ
ICPC and ICJ are co-located in the same unit: (If "No" - Agency under which each compact is administered.)
NO - ICJ is administered under the Department of Juvenile Justice and ICPC is administered under Health and Human Services
If ICPC and ICJ both apply to a case, North Carolina will coordinate services: (If "No" - Which Compact Supersedes)
YES
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Interstate Compact on the Placement of Children
I.
What is the Interstate Compact on the Placement of Children?
The Interstate Compact on the Placement of Children (ICPC) facilitates cooperation among
the 50 party states, the District of Columbia, and the U.S. Virgin Islands via a legally binding
agreement aimed at protecting children who are placed across state lines. The ICPC is
designed to obtain information before placing a child in another state and to ensure the two
states (receiving and sending) work together to place the child in a safe environment with
monitoring following the child’s placement. Placements that are covered by the ICPC cannot
occur unless prerequisites set out in the ICPC have been met. The Compact is not a federal
law. Rather, each member state has enacted the Compact and related provisions as state law.
In North Carolina the ICPC is found in Article 38 of the Juvenile Code1 (G.S. 7B-3800
through 7B-3806).
Each member state has a designated Compact Administrator to generally coordinate activities
under the ICPC and to be a member of The Association of Administrators of the Interstate
Compact on the Placement of Children. The AAICPC is authorized to “promulgate rules and
regulations to carry out more effectively the terms and provisions of this Compact.” G.S. 7B3800, Art. VII. Information about The AAICPC can be found on its web page,
http://www.aphsa.org/content/AAICPC/en/home.html.. The ICPC Regulations2 promulgated
by the AAICPC provide substantially more detail than the Compact itself. Some of the
regulations include:

No. 2 (effective Oct. 1, 2011): home study and placement decisions for children who
are under the jurisdiction of a court for abuse, neglect, or dependency and a child
welfare agency is looking at out-of-state placement for adoption, foster care and/or
with parents, or relatives. Exception: parent from whom the child was not removed,
and the court has no evidence that the parent is unfit.

No. 3 (effective Oct. 1, 2011): ICPC applicability, exemptions, and definitions.

No. 4 (effective Oct. 1, 2012): placement in a residential facility (a facility providing
24 hour supervised care beyond what is needed for assessment or treatment of an
acute condition, but does not include primarily educational institutions or medical
facilities that treat the acutely ill.

No. 7 (effective Oct. 1, 2011): expedited placement decision with an out-of-state
parent, stepparent, grandparent, adult uncle or aunt, adult brother or sister, or
guardian.

No. 11 (effective Oct. 1, 2010): Responsibility of the supervising (receiving) state
1
2
http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_7B/Article_38.html.
http://www.aphsa.org/content/AAICPC/en/ICPCRegulations.html.
II.
When does the ICPC apply?
A. The ICPC Statute applies to:
1. Placement of a child who is in DSS custody (or placement responsibility) with
relatives, in foster care, or with a pre-adoptive family in another state.
2. Placement of a child by any person or entity into another state for the purpose of
adoption.
3. Placement of a child by any person or entity into a licensed residential treatment
center in another state.
B. The ICPC Statute does not apply to:
1. Placement of a child by the child’s parent, step-parent, grandparent, adult sibling,
adult uncle, adult aunt, or legal guardian with any such relative or guardian in another
state. (See G.S. 7B-3800, Article VIII)
2. Placement of a child in residential school or in a medical facility or psychiatric
institution located in another state [See G.S. 7B-3800, Article II(d)] .
3. Divorce, paternity, custody and probate actions where the child is being placed with
parents, relatives, or non-relatives.
4. Placement of a (non-delinquent) child who is under the court’s jurisdiction with an
out-of-state parent, if all of the following conditions exist:
 the court does not have evidence that the parent is unfit to care for the child;
 the court does not seek evidence with regard to the parent’s fitness;
 when the placement is made, no request to place the child with the parent has
been submitted to the other state’s ICPC office;
 the ICPC office in the state where the parent lives has not previously denied a
request to place the child with the parent; and
 the court terminates its jurisdiction over the child when the child is placed with
the parent.
C. The ICPC Regulation No. applies the ICPC to:
1. Placement by the court or DSS of a (non-delinquent) child who is under the court’s
jurisdiction, with an out-of-state parent,
 if the court or DSS has evidence that the parent may be unfit to care for the child,
 if the court seeks evidence from the receiving state that the parent is unfit, and
 the court will not relinquish jurisdiction over the child immediately upon
placement with the out-of-state parent
2 III.
Is the law settled with respect to placements with out-of -state parents?
NO
A. NC Case Decision
In 2004 the North Carolina Court of Appeals held that the provisions of the ICPC did not
apply at a permanency planning hearing when the court awarded custody to an out-ofstate mother. In re Rholetter, 162 N.C. App. 653 (2004). In that case the children had
been removed from the custody of the father and stepmother in North Carolina, based on
adjudications of abuse and neglect, and placed in DSS custody. The court eventually gave
custody to the mother who lived in South Carolina, even though two home studies by SC
declined to approve the placement. The court of appeals held that the award of full
custody to a non-removal parent was not a “placement” under the ICPC. The court found
that the language of the ICPC was "clear and unambiguous" and that because the trial
court had not placed the children "in foster care or as a preliminary [placement] to
adoption," the ICPC did not apply. Rholetter, 162 N.C. App at 664. The court further
found that the trial court determines what is in the best interests of the child based upon
sufficient evidence presented to it at trial, and is therefore, not obligated to follow the
home study recommendations, just as it does not always follow a DSS recommendation.
B. What about the ICPC Regulations as amended?
The court of appeals did not mention the ICPC Regulations in Rholetter; instead it relied
on the plain wording of the ICPC itself.
However, in 2011 and 2012, the AAICPC substantially rewrote some of the ICPC
regulations, including Regulation 3, which covers definitions, placement categories,
applicability, and exemptions. Under Regulation 3, placement categories that require
compliance with the ICPC include:
1. Placements preliminary to adoption (whether the adoption is independent, private, or
public)
2. Placements with related or unrelated caregivers, in licensed or approved foster homes
3. Placements with parents and relatives when a parent or relative is not making the
placement
4. Placements in group homes and other residential placements in institutions in other
states (as defined in Article VI and Regulation No. 4)
Below are some of the definitions from Regulation 3 that demonstrate the breadth of its
intended scope:

Family free (a term used in the ICPC to describe a covered placement category): "the
home of a relative or unrelated individual whether or not the placement recipient
receives compensation for care or maintenance of the child, foster care payments, or
any other payments or reimbursements on account of the child's being in the home of
the placement recipient (has same meaning as boarding home)."
3 
Foster care: "If 24-hour-a-day care is provided by the child's parent(s) by reason of a
court-ordered placement (and not by virtue of the parent-child relationship), the care
is foster care." The term also "includes 24-hour substitute care for children placed
away from their parents or guardians and for whom the state agency has placement
and care responsibility. This includes, but is not limited to, placements in foster
family homes, foster homes of relatives, group homes, emergency shelters, residential
facilities, child care institutions and pre-adoptive homes. A child is in foster care in
accordance with this definition regardless of whether the foster care facility is
licensed and payments are made by the state or local agency for the care of the child,
whether adoption subsidy payments are being made prior to the finalization of an
adoption, or whether there is federal matching of any payments that are made."

Placement: "the arrangement for the care of a child in a family free, in a boarding
home or in a child-caring agency or institution, but does not include any institution
caring for the mentally ill, mentally defective or epileptic, or any institution primarily
educational in character, and any hospital or other medical facility."
Under both Regulation 2 and Regulation 3, placement with a parent is exempt from the
ICPC requirements only if all of the following are true:
1. The parent is not the parent from whom the child was removed.
2. The court has no evidence that the parent is unfit.
3. The court does not seek any evidence from the receiving state regarding the parent's
fitness.
4. The court relinquishes jurisdiction over the child immediately upon placement with
the parent.
This language is broader than the language of the statute. No North Carolina cases
address the effect in North Carolina of the amended ICPC Regulations as related to
parents. If the regulation applies, the holding in Rholetter would be contrary to the
language of the regulation.
The Connecticut Supreme Court addressed the question of whether the ICPC and its
current regulations applied to the placement of children with an out-of-state noncustodial
parent. In re Emoni W., 305 Conn. 723, 48 A.3d 1 (2012). Applying the same reasoning
as the North Carolina Court of Appeals in Rholetter, the Connecticut Supreme Court
concluded that the ICPC’s language, “placement in foster care or as a preliminary to a
possible adoption,” does not include placement with a noncustodial parent. The court
went on to say that “it is reasonable to conclude that the drafters determined that the
statute should not be applied to out-of-state parents in light of the constitutionally based
presumptions that parents generally are fit and that their decisions are in the child's best
interests.” In re Emoni W., 305 Conn. at 736, 48 A.3d at 8. The court went on to state in a
footnote that even if the ICPC regulations have the force of law, they are invalid to the
extent they impermissibly expand the scope of the compact itself. Similarly, but without
reference to the regulations, a California Court of Appeals held that "[c]ompliance with
the ICPC is not required for placement with an out-of-state parent." In re Patrick S. III,
218 Cal.App.4th 1254, 160 Cal.Rptr.3d 832, Cal.App. 4 Dist. (August 15, 2013).
4 In contrast, the Arizona Court of Appeals reached the opposite conclusion in Arizona
Dept. of Economic Sec. v. Standard, 323 P.3d 760 (Ariz. App. Div. 2) (May 5, 2014),
finding that the court was a “sending agency” and, therefore, the ICPC regulations
applied to placements with relatives and parents if none of the enumerated exceptions
applied.
Courtesy Check
The regulations do allow a state to request a “courtesy check” of a non-removal parent’s
home by the receiving state, without invoking the full ICPC home study process.
Whether to conduct a courtesy check is totally in the discretion of the receiving state.
When placement with a non-removal parent is made without ICPC compliance or with
only a courtesy check, the receiving state has no responsibility for supervising or
monitoring the placement.
IV.
How Does the Law Apply to Relatives?
The NC Juvenile Code specifically requires compliance with the ICPC whenever a child
is placed "with a relative outside of this State":



in an initial order for nonsecure custody [G.S. 7B-505(d)],
in an order for continued nonsecure custody [G.S. 7B-506(h)(2)], or
in a disposition order [G.S. 7B-903(a)(2)c.]
For Disposition Orders, see In re V.A., ___ N.C. App. ___, 727 S.E.2d 901 (2012). The
court of appeals held that the trial court’s placement of the child with a relative, the
maternal great grandmother, in South Carolina, required compliance with the ICPC
because the permanent plan was a concurrent one of reunification and adoption, thereby,
triggering ICPC as a placement preliminary to a possible adoption or foster care. The SC
authorities did not approve of the child’s placement with the maternal great grandmother,
which the court trial made as a finding of fact. Yet, the trial court ordered placement of
the child with the maternal great grandmother in SC. This violated the ICPC, and the
court of appeals reversed the dispositional order placing the child with an out-of-state
relative.
See also, In re L.L., 172 N.C. App. 689 (2005) which holds that that the ICPC applies to
out-of-state placements in nonsecure custody and disposition orders, as G.S. 7B-505, 506, and -903 specifically refer to the compliance with the ICPC. The court of appeals
further held that the statutory preference for relative placement under nonsecure and
disposition orders and compliance with the ICPC are not mutually exclusive. Each statute
must be construed so as to give effect to each, so that even though an ICPC takes time
and may not be completed until a review hearing, the court must consider relative
placement upon completion of the ICPC unless it finds the placement is not in the child’s
best interests.
5 Relying on Rholetter, the court of appeals later held that the ICPC did not apply to a
permanency planning order that awarded guardianship pursuant to G.S. 7B-600 to
grandparents in Virginia. The court reasoned that the permanency planning order of
guardianship was not a “placement” triggering the ICPC because it was neither foster
care nor a preliminary [placement] to an adoption. In re J.E., 182 N.C. App. 612 (2007).
The majority distinguished In re L.L., 172 N.C. App. 689 (2005), which had held that the
ICPC applied to out-of-state relative placements under G.S. 7B-505 (nonsecure custody)
and 7B-903 (disposition), noting that those statutes specifically require ICPC compliance,
while neither the guardianship nor permanency planning statute mentions the ICPC.
The same question about the applicability of regulation 3 in North Carolina applies to
placement with out-of-state relatives pursuant to post-disposition as with out-of-state
parents.
V.
Can a child visit out of state without ICPC compliance?
Regulation 9 states that visits and placements are different by virtue of purpose, duration, and
the intention of the person or agency responsible for determining the child's place of abode.
Under the ICPC, a visit is a temporary stay to provide a child with a social or cultural
experience of short duration. It may last no longer than 30 days or, for a school-aged child,
the period of a school vacation. The ICPC does not apply to visits, and a receiving state does
not conduct home studies for or supervise visits. If the sending state has requested a home
study or supervision and sends the child to stay with the proposed caregiver in the receiving
state, there is a rebuttable presumption that it is a placement and not a visit.
VI.
The federal law that references ICPC
Safe and Timely Interstate Placement of Foster Child Act of 2006, P.L. 109-239 (July 3,
2006), effective October 1, 2006
Purpose: “to improve protections for children and to hold States accountable for the safe and
timely placement of children across State lines…”
Amendments include the addition of the following subsections:
42 U.S.C. 671(a)(25) “provide that the State shall have in effect procedures for the orderly
and timely interstate placement of children; and procedures implemented in accordance with
an interstate compact….”
42 U.S.C. 671(a)(26)
(A)(i) “within 60 days after the State receives from another State a request to conduct a study
of a home environment for purposes of assessing the safety and suitability of placing a child
in the home, the State shall, directly or by contract
6 (I)
(II)
conduct and complete the study, and
return to the other State a report on the results of the study, which shall
address the extent to which the placement in the home would meet the
needs of the child….
(B) the State shall treat any report … that is received from another State or an Indian tribe
(or from a private agency under contract with another State) as meeting any requirements
imposed by the State for the completion of a home study before placing a child in the
home, unless, within 14 days after receipt of the report, the State determines, based on
grounds that are specific to the content of the report, that making a decision in reliance on
the report would be contrary to the welfare of the child; and
(C) the State shall not impose any restriction on the ability of a State agency
administering, or supervising the administration of, a State program operated under State
plan... to contract with a private agency for the conduct of a home study….”
7 INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
CHECKLIST FOR INTERSTATE PLACEMENT REQUESTS:
A How To Guide On Completing An ICPC Referral
The Information Listed Below Applies to Public Agency Placements
(Except Psychiatric Residential Treatment Facility Placements)
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
Cover letter requesting ICPC services
ICPC 100A completed and signed by agency staff
ICPC 100B completed and signed by agency staff if family unit has
already moved
Current custody order
Current case history for the child
Case medical/financial plan on each child along with documentation of
IV-E eligibility and/or adoption assistance eligibility
Service/Case/Permanency Plan
Copy of Birth Certificate and Social Security Card
Psychological evaluation
Educational information
Medical Information
Case manager Statement of Interest as required for Regulations 2 & 7
ICPC 101 Priority Home Study Request completed for all Expedited
Requests
Expedited court order for Regulation 7 (expedited) cases (remember
expedited requests should be in the NC ICPC within 3 days)
If an adoptive placement, include legal clearance documents &
adoption profile.
If an adoptive placement, include pre-placement assessment, if
available
If an adoptive placement, include background information on birth
family
Additional guidance:
Items A-L should always be included in the placement request in triplicate copies
per placement resource. The only exception is the 100A, which requires 5 copies
per child.
Items M-Q are conditional and are based on the type of placement requested.
When these items are included in the request, please include triplicate copies per
placement resource. Remember 5 copies per child of the 100A. ICPC 101 will
always be the top page in all Expedited Requests.
Arrange packages with the cover letter and other common documents to all
children on top; put the child specific information underneath.
For additional assistance in preparing a request for ICPC, please contact the
North Carolina Division of Social Services’ ICPC office at 919-527-6390.
DSS-5255 (Rev. 03/2014)
Child Welfare Services
Page 1 of 1
ICPC 100A
REV. 8/2001
Please type
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN REQUEST
FROM: N.C. Division of Social Services
st
820 S. Boylan Ave., 1 Floor, McBryde Building East
Raleigh, North Carolina 27603-2246
TO:
Notice is given of intent to place - Name of Child:
Social Security Number
Title IV-E determination
Yes
No
Yes
No
Unable to determine/unknown
Native Hawaiian/ Other
Pacific Islander
Race:
American Indian or
Alaskan Native
Asian
ICWA Eligible
Yes
No
Date of Birth
Sex:
SECTION I - IDENTIFYING DATA
Ethnicity: Hispanic Origin:
Black or African American
White
Pending
Name of Mother
Name of Father:
Phone:
Name of Agency or Person Responsible for Planning for Child:
Address:
Name of Agency or Person Financially Responsible for Child:
Phone:
Address:
SECTION II - PLACEMENT INFORMATION
Name of Person(s) or Facility Child is to be placed with:
Address:
Type of Care Requested:
Foster Family Home
Group Home Care
Child Caring Institution
Residential Treatment Center
Institutional Care-Article VI,
Adjudicated Delinquent
Current Legal Status of Child:
Sending Agency Custody/Guardianship
Parent Relative Custody/Guardianship
Court Jurisdiction Only
ADOPTION
IV-E Subsidy
Non IV-E Subsidy
To Be Finalized In:
Sending State
Receiving State
Parent
Relative (Not Parent)
Relationship:
Other
Protective Supervision
Parental Rights Terminated-Right to Place for Adoption
Unaccompanied Refugee Minor
Other
SECTION III - SERVICES REQUESTED
Initial Report Requested (if applicable):
Supervisory Services Requested:
Parent Home Study
Request Receiving State to Arrange Supervision
Relative Home Study
Another Agency Agreed to Supervise
Adoptive Home Study
Sending Agency to Supervise
Foster Home Study
Name and Address of Supervising Agency in Receiving State:
Enclosed:
Soc Sec # (optional):
Soc Sec # (optional):
Phone:
Child's Social History
Home Study of Placement Resource
Court Order
ICWA Enclosure
Supervisory Reports Requested:
Quarterly
Semi-Annually
Upon Request
Other
Financial/Medical Plan
IV-E Eligibility Documentation
Signature of Sending Agency or Person:
Date:
Signature of Sending State Compact Administrator, Deputy or Alternate:
Date:
Other Enclosures
SECTION IV - ACTION BY RECEIVING STATE PURSUANT TO ARTICLE III(d) of ICPC
Placement may be made
Placement shall not be made
REMARKS:
Signature of Receiving State Compact Administrator, Deputy or Alternate:
Date:
DISTRIBUTION (Complete six (6) copies):
• Sending Agency retains a (1) copy and forwards completed original plus four (4) copies to:
• Sending Compact Administrator, DCA, or alternate retains a (1) copy and forwards completed original and three (3) copies to:
• Receiving Agency Compact Administrator, DCA, or alternate who indicates action (Section IV) and forwards a (1) copy to receiving agency and the completed original and one (1) copy to sending Compact Administrator, DCA, or alternate within 30 days.
• Sending Compact Administrator. DCA, or alternate retains a completed copy and forwards the completed original to the sending agency.
DSS-1837 (Rev. 03/2014)
Child Welfare Services
Page 1 of 1
(ICPC 100A)
F
One form per child
Please type
ICPC 100B
REV. 8/2001
INTERSTATE COMPACT REPORT ON CHILD'S PLACEMENT STATUS
FROM:
TO:
N.C. Division of Social Services
st
820 S. Boylan Ave., 1 Floor, McBryde Building East
Raleigh, North Carolina 27603-2246
SECTION I - IDENTIFYING
INFORMATION
Child's Name:
Birthdate:
Father's Name:
Mother's Name:
Initial Placement of Child in
Name of Resource:
Address:
Type of Care:
Placement Change
SECTION II - PLACEMENT
STATUS
Receiving State
Date Child Placed in Receiving State:
Effective Date of Change:
Name of Resource:
Address:
Type of Care:
SECTION III - COMPACT PLACEMENT TERMINATION
In Receiving
Court Order Attached
In Sending
Adoption Finalized
Child Reached Majority/Legally Emancipated
Legal Custody Returned to Parent(s)
Court Order Attached
Legal Custody Given to Relative
Court Order Attached
Relationship:
Name:
Treatment Completed
Sending State's Jurisdiction Terminated with the Concurrence of the Receiving State
Unilateral Termination
Child Returned to Sending State
Child Has Moved to Another State
Proposed Placement Request Withdrawn
Name of Placement Resource:
Approved Resource Will Not Be Used for
Name of Approved Placement
Other (Specify):
Date of Termination:
SECTION IV - SIGNATURES
Person/Agency Supplying Information:
Date:
Compact Administrator, Deputy or Alternate:
Date:
DISTRIBUTION (Complete four (4) copies of this form):
Sending Agency retains a (1) copy and forwards completed original plus three (3) copies to:
Sending Compact Administrator, DCA, or alternate retains one (1) copy and forwards two (2) copies to:
Receiving Agency Compact Administrator, DCA, or alternate retains one (1) copy and forwards one - 1) copy to the receiving agency
DSS-1838 (Rev. 03/2014)
Child Welfare Services
(ICPC 100B)
Page 1 of 1
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
SENDING STATE PRIORITY HOME STUDY REQUEST
Form ICPC 101 (Regulation .01)
To be submitted by Social Worker with other required ICPC materials
Name of Child 1 to be placed: ____________________________ Age: ________ Mother’s Name: ___________________
Ethnic Group: _________________________________________ DOB: _______ Father’s Name: ___________________
PROPOSED CARETAKER
Name: ________________________________ Marital Status: S, M, Sep., D, W Living with: ____________________
(circle one)
(name of person)
Address: ___________________________________________________________________________________________
Telephone Number: (Home) _(___)_____________ (Work) _(___)___________ Social Security Number: _____________
Relationship to child identified above: ___________________________________________________________________
Best time to contact caretaker: ______ Employer: __________________________________________________________
(if applicable)
Alternate Contact Name & Address: _____________________________________________________________________
___________________________________________________________________________________________________
ASSESSMENT OF CHILD
Case Plan attached: YES NO
Financial/Medical Plan attached: YES
(circle one)
NO
(circle one)
Special Needs: ______________________________________________________________________________________
Handicaps: Mental/Physical ___________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Services Needs/Treatment Requirements: _________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
School Information: __________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Other required pertinent information regarding child and family will follow:
YES
NO
(circle one)
Worker’s Name: _______________________________________________________ (____)________________________
(please print)
(telephone number)
Worker’s Signature: __________________________________________ _________ (____)________________________
(date)
(fax number)
Supervisor’s Signature: _______________________________________ _________ (____)________________________
(if required)
1
(date)
(telephone number)
If there is more than one child to be placed with the proposed caretaker, list the name of the child(ren) and all
requested information on a separate page and attach to this form.
DSS-5252
Family Support and Child Welfare Services
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
Form ICPC 102 (Regulation .02)
RECEIVING STATE PRIORITY HOME STUDY REQUEST
EACH SECTION MUST BE COMPLETED
Name of Child 1 to be placed: ____________________________ Age: ________ Sending State: ___________________
Ethnic Group: ________________________________________ DOB: _______________________________________
Dates of telephone contacts: ___________________________ Dates of Home Visits: ___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
PROPOSED CARETAKER/SPOUSE
Name: _______________________________________________ Social Security Number: _______________________
Address: _________________________________________________________________________________________
Telephone Number: (Home) _(_____)___________________
Marital Status: S
M Sep.
D
W
(Work) _(_____)_________________________
Living with: ___________________________________________________
(circle one)
(name of person)
Caretaker/Spouse: _________________________________________________________________________________
Employer’s Name & Address: _______________________________________________________________________
Employer’s Telephone Number: (_____)_______________________________________________________________
YOU MUST SUBMIT INCOME VERIFICATION
Income: $ _____________ yearly
monthly bi-weekly
weekly
(circle one)
Head of Household: ________________________________________________ (Name on rent receipts, utility bills, etc.)
Number of Members in Household: ____________________________________________________________________
Relationship to proposed caretaker: ____________________________________________________________________
Length of relationship (if not marital): __________________________________________________________________
Relationship of proposed caretaker to child: ______________________________________________________________
Reason for wanting to care for children: _________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How did you hear about child’s situation? ________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you understand the situation that caused this request? ____________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
1
If there is more than one child to be placed with the proposed caretaker, list the name of the child(ren) and all
requested information on a separate page and attach to this form.
DSS-5253
Family Support and Child Welfare Services
Page 1 of 6
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
Form ICPC 102 (Regulation .02)
Ability to protect child from offender: ___________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
Willingness to provide care (time limited?) (open-ended?) __________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Appropriateness of child care plans: _____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Forms of discipline: _________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
Is present income adequate? __________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
Willingness (ability) to care for child without financial help: _________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
Willingness to accept/apply for TANF?
YES _____
NO _____
Requests Foster Care benefits?
YES _____
NO _____
Willingness to undergo licensure?
YES _____
NO _____
SPECIAL NEEDS
Ability of caretaker, community, schools to meet child(ren)’s special needs: _____________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
OTHER ADULTS IN HOUSEHOLD (list separately/use additional sheet to list household members if needed)
Name: __________________________________________________________________________________ Age: ______
Relationship to proposed caretaker: _________________
Relationship to child to be placed: ____________________
Attitude towards placement: ___________________________________________________________________________
___________________________________________________________________________________________________
DSS-5253
Family Support and Child Welfare Services
Page 2 of 6
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
Form ICPC 102 (Regulation .02)
Name: __________________________________________________________________________________ Age: ______
Relationship to proposed caretaker: _________________
Relationship to child to be placed: ____________________
Attitude towards placement: ___________________________________________________________________________
___________________________________________________________________________________________________
OTHER CHILDREN IN HOUSEHOLD (list separately/use additional sheet to list household members if needed)
Name: __________________________________________________________________________________ Age: ______
Relationship to proposed caretaker: _________________
Relationship to child to be placed: ____________________
Attitude towards placement: ___________________________________________________________________________
___________________________________________________________________________________________________
School progress/problems: ____________________________________________________________________________
___________________________________________________________________________________________________
Previous contacts with public/social services agencies: ______________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Name: __________________________________________________________________________________ Age: ______
Relationship to proposed caretaker: _________________
Relationship to child to be placed: ____________________
Attitude towards placement: ___________________________________________________________________________
___________________________________________________________________________________________________
School progress/problems: ____________________________________________________________________________
___________________________________________________________________________________________________
Previous contacts with public/social services agencies: ______________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
CLEARANCES (in accordance with receiving state law)
Law enforcement/child abuse and neglect clearances for all household members who have reached the age of majority:
Police: ____________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Child Abuse and Neglect: _____________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Family known to public/social services agencies (if yes, please explain): ________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
DSS-5253
Family Support and Child Welfare Services
Page 3 of 6
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
Form ICPC 102 (Regulation .02)
HEALTH
Proposed caretaker and other family members state that they are in basic, good health and free of communicable diseases:
YES _____
NO _____ (if no, please explain) _________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
HOME AND COMUNITY
Adequacy of space: __________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
Will the child have his/her own bed: YES ___
Will the child share a bedroom? YES ___ NO ___
NO ___
Closet space? YES ____
NO ____
(if yes, list name(s) below)
With whom? _______________________________________________________________________________________
___________________________________________________________________________________________________
Housekeeping standards: ______________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Viewed potential hazards, safety problems (please specify): __________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Appropriateness of neighborhood: ______________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Proximity to schools, medical services, etc.: _______________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
AREA OF CONCERN
Did you visualize or anticipate any potential problem areas with this case (explain): _______________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
DSS-5253
Family Support and Child Welfare Services
Page 4 of 6
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
Form ICPC 102 (Regulation .02)
CASE PLAN FROM SENDING STATE
Is the submitted case plan suitable/adequate for this proposed placement? YES ___
NO ___ (if no, explain)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Do you have any recommended changes in the case plan or goal? ______________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Are there any restrictions or limitations you would place on the proposed family, the court, the placing agency?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Financial/Medical Plan from Sending State is adequate for this child? YES ___
NO ___ (if no, explain)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
STUDY NARRATIVE
Discuss any areas that cannot be addressed by this abbreviated study. Please explain or expound upon any area that needs
clarification: ______________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Worker’s Recommendations: For Placement ______
Against Placement _______ (explain below)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Comments (if appropriate): ____________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
Please list conditions, if any, for placement to occur: _______________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
DSS-5253
Family Support and Child Welfare Services
Page 5 of 6
INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
Form ICPC 102 (Regulation .02)
Agency: __________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________
City: ___________________________________________________ State: ________ Zip Code: _________________
Name of Worker: _______________________________
Name of Supervisor: ______________________________
(please print)
(please print)
Title: _________________________________________
Title: ___________________________________________
Worker’s Signature: _____________________________
Supervisor’s Signature: _____________________________
Date: _________________________________________
Date: ___________________________________________
Telephone Number: (____)________________________
Telephone Number: (_____)_________________________
REFERENCES
Name: _____________________________________________________________________________________________
Street Address: ______________________________________________________________________________________
City: _________________________________________
State, Zip Code: ___________________________________
Home Telephone Number: (_____)__________________
Work Telephone Number: (_____)____________________
Made Contact: YES ___
Positive ___ Negative ___
NO ___
(if negative, explain below)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Name: _____________________________________________________________________________________________
Street Address: ______________________________________________________________________________________
City: _________________________________________
State, Zip Code: ___________________________________
Home Telephone Number: (_____)__________________
Work Telephone Number: (_____)____________________
Made Contact: YES ___
Positive ___ Negative ___
NO ___
(if negative, explain below)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Name: _____________________________________________________________________________________________
Street Address: ______________________________________________________________________________________
City: _________________________________________
State, Zip Code: ___________________________________
Home Telephone Number: (_____)__________________
Work Telephone Number: (_____)____________________
Made Contact: YES ___
Positive ___ Negative ___
NO ___
(if negative, explain below)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
DSS-5253
Family Support and Child Welfare Services
Page 6 of 6
NC Interstate Compact
Order of Compliance
IN THE ____________ COURT OF THE STATE OF ____________
IN RE: CHILD’S NAME DOB
REGULATION 7 FORM ORDER FOR EXPEDITED PLACEMENT DECISION
PURSUANT TO THE ICPC
THIS CAUSE came on to be heard on __________ before the court on the motion/petition of
___________ (party making request) seeking the entry of this order for compliance with
Regulation 7 of the Interstate Compact on the Placement of Children (ICPC); and the court,
hearing evidence and/or the parties being in agreement, does find as follows:
A. The name and date of birth of each child noted below on this date is as follows:
_______________________________________________ (Name of child, date of birth)
_______________________________________________ (Name of child, date of birth)
_______________________________________________ (Name of child, date of birth)
B. This court has jurisdiction over each child noted pursuant to Articles II, III and V(a) of
the ICPC to invoke the Compact for the purpose of requesting one or more home study
assessments and expedited placement decisions on potential resource families living in
one or more receiving states.
C. Pursuant to Article III(d) of the Compact, this court may only place, or authorize the
department/agency to place, each child above in an approved placement in a receiving
state, including a provisional placement as authorized by Regulation 7 of the ICPC, after
receipt of written notification from the receiving state that the proposed placement does
not appear to be contrary to the interests of the child.
D. If any child above is placed pursuant to paragraph C above, this court will retain
Article V(a) jurisdiction over that child sufficient to determine all matters in relation to
the custody, supervision, care and disposition of him/her, which it would have if the child
had remained in this state; and this court will not terminate jurisdiction over said child or
terminate the supervisory responsibility of the department/agency having custody of the
child during the period of placement in the receiving state until the child is adopted,
reaches the age of majority, becomes self-supporting, or is discharged with concurrence
of the appropriate authority in the receiving state.
E. This court expressly finds that its jurisdiction over said child includes the power to
effect or cause the return of the child to this state or its transfer to another location or
custodian pursuant to law within five (5) business days of receipt of written notification
from the receiving state Compact Administrator that placement authorization will not be
approved or that previous placement approval has been withdrawn by the receiving state,
and that the sending state has and will continue to have financial responsibility for
support and maintenance of the child during the period of placement in the receiving
state.
Further, this court order provides sufficient authority and direction for the sending agency
to immediately return said child(ren) within five (5) working days of receipt of written
notification from the receiving state Compact Administrator that placement authorization
DSS-1839 (Rev. 2/2012)
Child Welfare Services
ICPC Order of Compliance
Page 1 of 4
NC Interstate Compact
Order of Compliance
will not be approved, or that previous placement approval has been withdrawn by the
receiving state for reasons determined by the receiving state.
F. If any child noted above is sent, or allowed to go, to a provisional placement in a
receiving state, this court finds that any such placement must be in compliance with
Regulation 7 of the ICPC of which this court takes judicial notice, including its purpose
in defining and regulating a provisional placement under the Compact.
AND THE COURT having heard testimony and argument of counsel and any unrepresented
parties and reviewed documents as permitted by law and Regulation 7 of the ICPC, the
undersigned makes the following findings of fact by
( ) clear and convincing evidence
( ) a preponderance of the evidence
that paragraphs 5, 6, and 7 of Regulation 7 of the ICPC apply regarding each child noted above:
G. __________________________ (relative’s name) is the proposed placement resource
in the
receiving state of ________________ and is the
a. ____ Mother d. ____ Grandparent
b. _____Father e._____ Adult brother or sister
c. _____Stepparent
f. _____Adult uncle or aunt
g. _____Guardian
of __________________________(child noted above); and
H. Each child noted above is under the jurisdiction of the court as a result of action taken
by a child welfare agency.
I. The child __________ referenced in A. meet(s) one or more of the following
requirements pursuant to paragraph 5 of Regulation 7:
1. The court has the authority to determine custody and placement of each child
or has delegated said authority to the child welfare agency, and each child is
being considered for placement in another state with a parent, stepparent,
grandparent, adult brother or sister, or adult aunt or uncle, or guardian of the
child named in A, and the child in A above meets the following criteria:
a. ( ) unexpected dependency due to sudden or recent incarceration,
incapacitation or death of a parent or guardian; incapacitation means a
parent or guardian is unable to care for a child due to an unexpected
medical, mental or physical condition of a parent or guardian, or
b. ( ) at least one of the children sought to be placed is four years of age
or younger, including older siblings sought to be placed with the same
proposed placement resource; or
c. ( ) the court finds that ___________ (child’s name), is one of the
children in a sibling group sought to be placed and has a substantial
relationship with the proposed placement resource; substantial
relationship means the proposed placement has spent more than cursory
time with the child, is known to the child, and has established more than
a minimal bond with the child; or
DSS-1839 (Rev. 2/2012)
Child Welfare Services
ICPC Order of Compliance
Page 2 of 4
NC Interstate Compact
Order of Compliance
d. ( ) the child(ren) is/are currently in an emergency placement.
J. The department/agency has provided the court with a signed statement(s) from the
potential placement resource(s) or the assigned case manager in the sending state that
following a conversation with the potential placement resource, the potential placement
resource confirms/meets the minimum requirements as required under Paragraph 7a of
Regulation 7.
K. The sending agency has completed and is prepared to send all required paperwork to
the sending state ICPC office, including the statement from the prospective placement
resource or the assigned case manager under Paragraph 7a of Regulation 7, ICPC 100A
and ICPC Form 101.
IN CONSEQUENCE OF THE FOREGOING, IT IS, THEREFORE, ORDERED
AND ADJUDGED AS FOLLOWS:
1. This court, having jurisdiction over the above referenced child(ren), invokes the use of
the Interstate Compact on the Placement of Children and authorizes and directs this
state’s department/agency having custody of the child(ren) to be the sending agency in
this/these matter(s) and directs it to complete, execute, and file all necessary forms and
carry out and effectuate all obligations and responsibilities as the sending agency under
the Compact.
2. The department/agency shall seek the following:
a. ( ) Approval for a provisional placement of each child noted above in the
receiving state pending a more comprehensive home assessment of the potential
placement resource by the receiving state and an expedited placement decision
regarding final placement of the child(ren), or
b. ( ) A comprehensive home assessment of the potential placement resource in
the receiving state and an expedited placement decision without a provisional
placement of the subject child(ren), or
c. ( ) Approval for a provisional placement with a parent from whom the child
was not removed and concurrence to relinquish jurisdiction upon final approval.
3. The transmission of any documentation or request for information in this case/these
cases or decisions made shall be sent by overnight mail, FAX or as an attachment to an email if approved by receiving state or such other equally expedient method as may in the
future become available.
4. The court designates the clerk of court to send copies of this and other orders needed to
comply with Regulation 7 of the ICPC to the sending department/agency within two (2)
business days of the entry of this and other orders entered in this case:
a. name________________________________________
b. mailing address______________________________
c. e-mail address _______________________________
d. telephone number____________________________
e. FAX number _________________________________ DSS-1839 (Rev. 2/2012)
Child Welfare Services
ICPC Order of Compliance
Page 3 of 4
NC Interstate Compact
Order of Compliance
5. The person designated to receive communication regarding the progress of the ICPC
process in this/these matter(s) is:
a. name________________________________________
b. mailing address______________________________
c. e-mail address _______________________________
d. telephone number____________________________
e. FAX number _________________________________
6. The sending department/agency shall transmit, within three (3) business days of receipt
of this signed order, a completed Form 100A and 101 (Request for Placement), and if not
already sent, all required documentation for compliance with Regulation 7 and any
supporting documentation pursuant to ICPC Article III, to the sending state Compact
Administrator.
7. Within a time not to exceed two (2) business days after receipt of a complete
Regulation 7 request, the sending state Compact Administrator shall transmit the
complete request for the assessment and for any provisional placement to the receiving
state Compact Administrator. The request shall include a copy of this Order of
Compliance. In the event the sending state Compact Administrator finds that the ICPC
documentation received is substantially insufficient, he or she shall specify to the sending
agency what additional information is needed and request such information from the
sending agency.
8. When a provisional placement sought by the sending state is approved by the receiving
state for the subject child(ren), the receiving state Compact Administrator shall
immediately notify the sending state Compact Administrator of that fact in writing
through expedited means. Said person designated shall then seek an early hearing by this
court to determine if said placement is in the best interests of the child(ren).
The person designated to receive communication in Paragraph 4 above shall maintain
contact with the sending state’s Compact Administrator to assist this court in determining
the status of the ICPC process and shall report in writing to the court, the parties, and
their counsel regarding said status no later than 7 days prior to any scheduled court
hearing and provide any updates closer to the hearing date as may come to his/her
attention. The sending state’s Compact Administrator shall cooperate with and work with
the above designated person and provide him/her with information and assistance
regarding the progress of the ICPC process for the cases of the subject child(ren).
9. This case/these cases is/are continued to ________________ at ____________
a.m./p.m. for further hearing on the status of the ICPC process to which the parties
present and their counsel are recognized to appear.
ENTERED THIS__________ DAY OF ____________________, 20__.
_________________________
Judge/Judicial Officer
DSS-1839 (Rev. 2/2012)
Child Welfare Services
ICPC Order of Compliance
Page 4 of 4
ICPC Supervision Report
30 day
Date of Report:
/
/
Name of Child(ren):
Name of Caretaker(s):
Address of Placement:
Courtesy Caseworker :
(Receiving State)
Phone Number:
(
)
-
Reporting Period:
Dates and locations of Face-to-Face Contact:
Briefly discuss child(ren)’s current circumstances, addressing child(ren)’s safety in current placement and
child(ren)’s well-being:
List any unmet needs, and recommendations to meet those needs: (Sending State is responsible for case planning
and for funding)
Recommendation:
Continue placement.
Continue supervision.
Terminate supervision.
Receiving State concurs with:
Continue with current permanency goal.
Return custody to parent, terminate jurisdiction.
Establish guardianship.
Other (specify):
OFFICIAL INTERSTATE COMPACT OFFICE USE ONLY:
The Receiving State Compact Administrator/Deputy Compact Administrator/ICPC Specialist concurs with this
recommendation.
The Receiving State Compact Administrator/Deputy Compact Administrator/ICPC Specialist does not concur with
this recommendation.
/
Name
Date
DSS-5331 (Eff. 12/2010) Child Welfare Services
ICPC Supervision Form – 30 Day Report
Page 1 of 1
/
Revised 4-10
ICPC Supervision Report
90 day
Date of Report:
/
/
Name of Child(ren):
Name of Caretaker(s):
Address of Placement:
Courtesy Caseworker :
(Receiving State)
Phone Number:
(
)
-
Reporting Period:
Dates and locations of Face-to-Face Contact:
Discuss child(ren)’s current circumstances, addressing child(ren)’s safety in current placement and child(ren)’s
well-being:
Child(ren)’s school performance, if applicable: (Attach copies of report card, IEP, evaluations, if applicable.)
Child(ren)’s health & medical status, including dates of medical and dental appointments and names of service
providers, if applicable: (Attach records, evaluations, therapy reports if applicable)
Assessment current placement and caretakers, e.g., (physical condition of the home, caretaker's commitment to
child, current status of caretaker and family, any changes in family, composition, health, financial situation,
work, legal involvement, social relationships; child care arrangements):
Permanent plan status: What progress has been made toward a permanent goal? Has the goal changed? Are
there any recommendations?
List any unmet needs, and recommendations to meet those needs: (Sending State is responsible for case planning
and for funding)
Recommendation:
Continue placement.
Continue supervision.
Terminate supervision.
Receiving State concurs with:
Continue with current permanency goal.
Return custody to parent, terminate jurisdiction.
Establish guardianship.
Finalize adoption.
Other (specify):
ICPC Supervision Form – 90 Day Report
Page 1 of 2
Revised 4-10
OFFICIAL INTERSTATE COMPACT OFFICE USE ONLY:
The Receiving State Compact Administrator/Deputy Compact Administrator/ICPC Specialist concurs with this
recommendation.
The Receiving State Compact Administrator/Deputy Compact Administrator/ICPC Specialist does not concur with
this recommendation.
/
Name
Date
DSS-5332 (Eff. 12/2010) Child Welfare Services
ICPC Supervision Form – 90 Day Report
Page 2 of 2
/