Interstate Foster Care Placement Agreement
Section 1: Child Information
Full Name
Date of Birth
Current State of Residence
Case/ID Number
Section 2: Sending State Agency
Agency Name
Contact Person
Title
Phone Number
Email Address
Address
Section 3: Receiving State Agency
Agency Name
Contact Person
Title
Phone Number
Email Address
Address
Section 4: Foster Home Information
Foster Parent(s) Name(s)
Home Address
Phone Number
Foster Home License Number
License Expiration Date
Section 5: Placement Details
Placement Start Date
Expected Duration
Reason for Placement
Special Needs/Services Required
Section 6: Financial Responsibility Agreement
Party Responsible for Financial Support
Health Coverage Arrangements
Other Financial Notes
Section 7: Consent and Signatures
Sending State Agency Representative
Date
Receiving State Agency Representative
Date
Foster Parent Signature
Date
Other (Specify)
Date