DATE:
TO: FROM:
(Receiving State)
(Sending State)
Name of Juvenile: DOB: Race: Sex:
*If known, *Ht: *Wt: *Eye Color: *Hair Color:
Status:
Sending State File #:
To reside with: OR Is residing with:
(Name)
Relationship: Telephone:
Address: City:
Reason for Adjudication/Commitment:
Date of Adjudication: Date of Commitment:
Minimum Parole/Probation Expiration
Date:
Maximum Parole/Probation
Expiration Date:
Anticipated Placement Date : Present Location:
We desire to transfer this juvenile on to your state:
Because his/her legal guardian resides in your state.
For the following reasons, with your consent:
Other
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
Name:
Title:
(Compact Official/Designee)
Referred by:
(Name – Please Print)
Referring Agency:
ICJ FORM IV | Rev. 0
-01-1
INTERSTATE COMPACT FOR JUVENILES
PAROLE OR PROBATION INVESTIGATION REQUEST
FORM IV
(probation/parole)
By checking this box, I confirm the validity of the
information contained within this form
*If available, attach photograph.
