INTERSTATE COMPACT ON JUVENILES PAROLE OR PROBATION INVESTIGATION REQUEST FORM IV FORM IV DATE: TO: FROM: (Receiving State) (Sending State) Name of Juvenile: Status: Parole To reside with: DOB: Probation OR Race: Sex: Sending State File # Is residing with: (Name) Relationship: Telephone: Address: ( ) - City/State: Zip: Reason for Adjudication/Commitment: Date of Adjudication: Date of Commitment: Minimum Parole/Probation Period: Maximum Parole/Probation Period: Anticipated Placement Date: Present Location: We desire to transfer this juvenile on parole probation to your state: Because his/her parent/legal guardian resides in your state. For the following reasons, with your consent: Other Comments: THE FOLLOWING MATERIALS ARE ENCLOSED: Cover letter IA/VI Application for Compact Services and Memorandum of Understanding and Waiver Petition(s) Order of Adjudication and Disposition Legal and Social History Parole/Probation Conditions (Agreement) School Transcript/Records Immunization Records Any other Pertinent Information FOR ICJ USE ONLY Signed: (Compact Official/Designee) Title: Referred by: (Name – Please Print) Referring Agency: This is the official ICJ Form IV 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 IV AJCA Policy and Procedure Manual REVISED JANUARY 2007 3.57 January 2007 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING ICJ FORM IV 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. Receiving state: state in which juvenile is residing or will reside. Sending state: state of probation/parole/adjudication; requesting state. Juvenile name, etc.: insert juvenile’s name and vital information as indicated. Status of juvenile: parole, probation or other; if other, please explain in space provided. Sending state file #: the case number given in your office to the juvenile’s file or case. To reside with/is residing with: check one and insert name of person(s) with whom juvenile will reside or does reside in the receiving state. Complete information regarding full address including phone number with area code, and relationship to the juvenile. Reason for adjudication/commitment: fill in adjudication or pending offenses for which juvenile is to be supervised. Date of adjudication: insert date of court-ordered supervision of the juvenile. Date of commitment: insert date of court-ordered commitment of the juvenile. Minimum parole/probation period: earliest date juvenile could be released from supervision. Maximum parole/probation period: latest date juvenile could be released from supervision. Anticipated placement date: approximate date juvenile is anticipated to arrive in this proposed home. Present location: insert current location of juvenile (at the time this request for supervision is being transmitted to the ICJ office). (Why) we desire to transfer this juvenile…: if the juvenile’s parent or legal guardian resides in the state, check the appropriate box; if the juvenile will be living with someone other than parent or legal guardian, complete the “for the following reasons” section. Check the appropriate boxes as to the enclosures that are being submitted with the referral packet. All applications should have a cover letter. Include at the very minimum: ICJ Forms IV and IA/VI, Petition/s, Order/s of Adjudication and Disposition, and Parole/Probation Conditions (Agreement). If a social history is available, it must be included as well. All other items are helpful to the successful investigation and supervision of this case by the proposed new state of residency. Referred by: Printed name of caseworker or officer making this request for supervision. Referring Agency: Print name of requester’s agency. AJCA Policy and Procedure Manual 3.58 January 2007 American LegalNet, Inc. www.FormsWorkFlow.com