Missouri Department of Social Services CHILDREN’S DIVISION INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN (ICPC) TRANSMITTAL CHECKLIST (Complete this form for Missouri children placed in another state.)
NAME(S) OF CHILDREN
COUNTY OFFICE
A CHECKMARK (√) ENTERED BY ITEMS 1 THROUGH 13 INDICATES THAT THE NECESSARY INFORMATION IS CONTAINED IN THE ICPC PACKET. ALL PAPERWORK WITH THE EXEPTION OF THE 100A IS TO BE IN TRIPLICATE. Please refer to the CWM, Sect 4, Chapt. 25, Subs.25.4.1
1. COVER LETTER	7. MEDICAL REPORT
2. ICPC 100-A (5 COPIES)	8. EDUCATIONAL REPORT(S)/IEP
3. SOCIAL SUMMARY	9. DOCUMENTATION OF ANY DIAGNOSED SPECIAL NEEDS OF CHILDREN
4. COURT ORDER (Custody Order & Most Recent)	10. DOCUMENTATION OF CITIZENSHIP
5. CASE PLAN/CS-1	11. FINANCIAL/MEDICAL PLAN (ICPC-3)
6. WRITTEN SERVICE AGREEMENT (For Parental Requests Only)	12. ICPC Initial Referral FACES CALL/CASE NUMBER: 13. ICPC 104 or ICPC 101a attached (required)
14. DOES THE COVER LETTER INDICATE EACH CHILD’S TITLE IV-E ELIGIBILITY?	YES NO
IF YES, IS TITLE IV-E DOCUMENTATION ATTACHED?	YES NO
15. DOES THE COVER LETTER IDENTIFY WHO IS RESPONSIBLE FOR PAYMENT OF EXPENSES?	YES NO
16. SIGNATURE OF CHILDREN’S SERVICE SUPERVISOR	DATE
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17. SIGNATURE OF CIRCUIT MANAGER/DESIGNEE	DATE
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COMMENTS FROM CS SPECIALIST/OTHER DESIGNEE (THIS SECTION TO BE COMPLETED AS APPROPRIATE)
SIGNATURE OF CS SPECIALIST/OTHER DESIGNEE	DATE
COMMENTS (THIS SECTION TO BE COMPETED BY CENTRAL OFFICE ICPC STAFF AS APPROPRIATE)
SIGNATURE OF ICPC COORDINATOR	DATE
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PLEASE SUBMIT IN TRIPLICATE (3) TO ICPC