Fillable Interstate Compact for Juveniles - Application for Compact Services

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Interstate Compact for Juveniles - Application for Compact Services

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ICJ FORM IA/VI | Rev. 02-23-15
INTERSTATE COMPACT FOR JUVENILES
APPLICATION FOR SERVICES AND WAIVER
FORM IA/VI
Form IA APPLICATION FOR COMPACT SERVICES
TO:
FROM:
(Receiving State)
(Sending State)
I,
,
Compact for Juveniles. I understand that supervision in the receiving state makes it likely that there will be certain
differences between the supervision that I would receive in this state and supervision that I will receive in the state to
which I am applying to relocate or reside. In order to receive the advantages of supervision under the Interstate Compact
for Juveniles, I hereby acknowledge and accept such differences in the standards of supervision as may be provided by
the receiving state.
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,
,
realize that the grant of parole probation and especially the privilege to
leave the State of
to go to the State of
is a benefit to me.
Therefore, I promise:
1.
That I will make my home with
(Name, Relationship, and Address)
until a change of residence is authorized by the proper authorities in the receiving state.
2. That I will obey the terms and conditions of parole probation as set 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 fail to keep 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. I understand and
accept that a failure to comply with these terms and conditions may result in sanctions in both the sending and/or
receiving state.
(Juvenile’s Signature)
(Date)
(Witness’ Signature)
(Date)
Permission is hereby granted to the above-named juvenile to apply for, reside in, and be supervised by the State of
provided that the receiving state accepts supervision.
(Receiving State)
(Date)
SIGNED:
(If probation, sending state’s JUDGE; If parole, sending state‘s COMPACT OFFICIAL)
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ICJ FORM IA/VI | Rev. 02-23-15
INSTRUCTIONS FOR COMPLETING ICJ FORM IA/VI
PLEASE TYPE OR PRINT LEGIBLY.
ALL MATERIALS MUST BE PROVIDED TO THE SENDING STATE’S INTERSTATE
COMPACT FOR JUVENILES OFFICE 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 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.
“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 for Juveniles official or designee signs
here.
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Interstate Compact for Juveniles - Application for Compact Services

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Completed 13 May 2020

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