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New sending case

Request a placement in another state

Step 4 of 5

Form 100A & 100B

Form 100A – Interstate Compact on the Placement of Children request

One 100A is created for each child in the case.

Organization or individualOrganizationIndividual

Agency name *

Address line 1 *

Address line 2

City *

State *

Zip code *

Phone *

Email address (optional)

Same as above

Organization or individualOrganizationIndividual

First name *

Last name *

Address line 1 *

Address line 2

City *

State *

Zip code *

Phone *

Email address (optional)

Initial report requested (if applicable)

Supervisory services requested *

Other supervisory services (specify) *

Supervisory reports requested *

Name of supervising agency in receiving state

Address line 1

Address line 2

City

State

Zip code

Child’s Social HistoryCourt OrderFinancial/Medical PlanOther EnclosuresHome Study of Placement ResourceICWA EnclosureIV-E Eligibility Documentation

Signature of sending agency or person

Sam OrtizSam Ortiz

Date11/10/2026

Signature of sending state compact administrator, deputy or alternate

Not signed

Date—

The receiving state completes this part after it reviews the request.

Action by receiving state

Placement approvedPlacement deniedPlacement approved – conditions apply

Remarks

Signature of receiving state compact administrator, deputy or alternate

Not signed

Date—

Form 100B – Report on child’s placement status

For REG 1 cases. Fill this in when the child is placed, the placement changes or the placement ends.

Initial placement of child in receiving state

Date child placed in receiving state

Placement change

Reason

Adoption FinalizedChild Reached Majority/Legally EmancipatedLegal Custody Returned to Parent(s)Legal Custody Returned to RelativeLegal Custody Returned to Other (specify)Treatment CompletedSending State’s Jurisdiction Terminated with the Concurrence of the Receiving StateUnilateral TerminationChild Returned to Sending StateChild Has Moved to Another StateProposed Placement Request WithdrawnApproved Resource Will Not Be Used for PlacementOther (specify)

Date of termination

Person or agency supplying information

Not signed

Date—

Compact administrator, deputy or alternate

Not signed

Date—

Case so far

Route: Nevada → Pennsylvania
Regulation: REG 1 - Intact Family Relocation
Type of care: Relative (Not Parent)
Children: Maya Thompson
Placement resource: Sunrise Children’s Home
Form 100A: One child · signed