INTERSTATE COMPACT ON JUVENILES APPLICATION FOR SERVICES AND WAIVER FORM IA/VI FORM IA/VI Form IA APPLICATION FOR COMPACT SERVICES TO: FROM: (Receiving State) (Sending State) I, , hereby apply for supervision as a parolee or probationer to the Interstate Compact on Juveniles. I understand that the very fact that supervision will be in another state makes it likely that there will be certain differences between the supervision I would receive in this state and supervision which I will receive in any state to which I am asking to go. However, I urge the authorities to whom this application is made, and all other judicial and administrative authorities, to recognize that supervision in another state, if granted as requested in this application, will be a benefit to me and will improve my opportunities to make a good adjustment. In order to get the advantages of supervision under the Interstate Compact on Juveniles, I do hereby accept such differences in the course and character of supervision as may be provided, and I do state that I consider the benefits of supervision under the Compact to be worth any adjustments in my situation which may be occasioned. In view of the above, I do hereby apply for permission to be supervised on parole probation in . (Receiving State) FORM VI MEMORANDUM OF UNDERSTANDING AND WAIVER I, leave the State of advantages, I promise: , realize that the grant of to go to the State of parole probation and especially the privilege to is a benefit to me. In return for these 1. That I will make my home with (Name, Relationship, and Address) until a change of residence is duly authorized by the proper authorities of the receiving state. 2. That I will obey and live up to the terms and conditions of parole probation as fixed by both the sending and receiving states. 3. That I will return at any time to the sending state if asked to do so by the parole probation authorities in that state. I further understand that if I do not obey or live up to these promises, I may be returned to the sending state. I have read the above or have had the above read and explained to me, and I understand its meaning and agree thereto. (Juvenile’s Signature) I, in my capacity as (Date) parent (Witness’ Signature) guardian of (Date) do approve and subscribe (Juvenile’s Name) to the above Memorandum of Understanding and hereby waive any right which I may have to contest the return of the juvenile referred to herein to the sending state or jurisdiction from any state or jurisdiction within or outside the United States, in which he she may be found. I also undertake to cooperate with the supervising authorities and to assist them in securing the return of the juvenile referred to herein to the sending state whenever, in their judgment, such return may be necessary or desirable. (Parent’s or Guardian’s Signature) (Date) (Witness’ Signature) (Date) Permission is hereby granted to the above-named juvenile and parent or guardian to allow the said juvenile to reside in and be supervised by the State of . (Receiving State) (Date) SIGNED: (If probation, sending state’s JUDGE; If parole, sending state‘s COMPACT OFFICIAL) This is the official ICJ Form IA/VI as approved by AJCA in August 2000. No state or other governmental entity party to the Interstate Compact on Juveniles may change, alter or otherwise modify any form that has been approved and adopted for use by the Association of Juvenile Compact Administrators. No other form may be substituted. (See Rule 3-103: Revision/Modification of Forms) ICJ FORM IA/VI AJCA Policy and Procedure Manual REVISED JANUARY 2007 3.59 January 2007 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING ICJ FORM IA/VI PLEASE TYPE OR PRINT LEGIBLY. ALL MATERIALS MUST BE PROVIDED TO THE SENDING STATE’S INTERSTATE COMPACT ON JUVENILES OFFICE IN TRIPLICATE, AND MUST BE DIVIDED INTO THREE SEPARATE, COMPLETE AND IDENTICAL PACKETS FOR FORWARDING. Form IA – Application for Compact Services Receiving state: state in which juvenile is residing or will reside. Sending state: state of probation/parole/adjudication; requesting state. “I…” (blank): print juvenile’s name here. “In view of the above…”: Check either “parole” or “probation” and fill in the name of the receiving state. Form VI – Memorandum of Understanding and Waiver “I,…” (blank): insert juvenile’s name, check “parole” or “probation,” fill in the name of the state under whose jurisdiction the juvenile is placed, and the name of the state in which the juvenile is residing or will reside. “1”: insert name, relationship, and address of home offer wherein juvenile is residing or will reside. “2”: check either “parole” or “probation.” “3”: check either “parole” or “probation;” Juvenile must sign and date; Witness must sign and date. “I, in my capacity…”: check appropriate relationship box; insert name of juvenile in blank; parent or guardian in the receiving state must sign and date; witness must sign and date. “Permission is hereby granted…”: insert name of state in which juvenile will reside and be supervised. “Signature”: If the juvenile is on probation, the sending state’s JUDGE or court designee signs here. If the juvenile is on parole, the sending state’s Interstate Compact on Juveniles official or designee signs here. AJCA Policy and Procedure Manual 3.60 January 2007 American LegalNet, Inc. www.FormsWorkFlow.com