INSTRUCTIONS FOR COMPLETING ICJ FORM V
PLEASE TYPE OR PRINT LEGIBLY.
When to complete this form: This form is to be completed if the juvenile is not already in the receiving
state on all transfer of supervision cases. In the case of a juvenile probationer departing to the receiving
state prior to the referral materials being sent to the receiving state’s ICJ Office and the case is, therefore,
unknown to the receiving state, the juvenile must be instructed to continue reporting to the sending state’s
probation officer. The “Out-of-State Travel Permit and Agreement to Return” form is used as a supplement
to the Form V. It is the responsibility of the supervising probation officer to ensure that the juvenile
receives a copy of the Travel Permit and that s/he is instructed to carry it on his/her person at all times until
supervision is picked up in the receiving state.
Rule 4-102: Supervision shall not be provided without written approval from the receiving state's ICJ
office. The sending state shall maintain responsibility until supervision is accepted by the receiving state.
Receiving state: state in which juvenile is residing or will reside.
Sending state: state of probation/parole/adjudication; state requesting cooperative supervision services.
Juvenile name, etc.: insert juvenile’s name and vital information as indicated.
Check the appropriate box: “plans to depart” OR “has departed” sending state; insert mode of
transportation; insert date of departure; check one: “in person” OR “by telephone” OR “by letter.”
Complete reporting instructions as indicated on receiving state’s report.
Check as applicable any enclosures.
Signed: The form is to be signed by the sending state’s case worker, parole/probation officer or ICJ
official; insert title and agency of signer as requested.
