The following is the list of documents required for an adoptive placement request through the
ICPC. This list demonstrates what is needed both from the Compact perspective as well as
the statutory and regulatory requirements in Pennsylvania. Additional forms may be required
by other party states in order to meet the requirements of their statute and regulation.
This list is complete as of March 27, 2015 and was compiled for the 2015 SWAN Quarterly
Meetings. Additional information was also included regarding the forms and documents
identified in this list.
For further detail or questions, contact the PA Interstate Compact Office, (717) 772-5505.
An adoptive ICPC placement request packet includes:
 A completed 100A form*;
 A Cover letter consisting of:
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Request for approval as well as the signature of the person requesting the approval;
Identifying the child, birth parent(s), adoptive parent(s), and supervising agency;
A statement regarding how the match was made;
Name of the intermediary (if any);
Name of the supervising agency;
Statement of change of placement from foster care to adoptive placement, or placement is a new
placement
 Consents* signed by the birth parents, all identified putative fathers, and husband;
 Jurisdictional waivers* and receiving state consents signed by the parties listed above; or
 An affidavit (dependent on situation); and
 A statement detailing how the rights of the party shall be legally addressed.
 Termination of Parent Rights Court Order(s).
 Statement of Compliance with Indian Child Welfare Act (25 U.S.C 1901, et. seq.);
 Birth Parent Information consisting of:
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Social history;
Medical history;
Ethnic background; and
Reasons for adoption plan.
 Current case history for the child containing:
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Custodial and social history;
Chronology of court involvement;
Educational information; and
Medical history and any special needs/services.
For infants a minimum of medical records of the birth and discharge summary are needed.
 Letter agreeing to supervise from receiving agency.
 Public agencies need statement of contract completion/negotiation on letterhead from the receiving
private agency.
Pennsylvania Interstate Compact Office
Division of Operations
Office of Children, Youth and Families
P.O. Box 2675 | Hillcrest Building, 2nd Floor | Harrisburg, PA 17105 | P 717.772.5505
F 717.214.7709 | www.dhs.state.pa.us
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February 7, 2016
Private Providers need to include:
o “At Risk” Statement if parental rights are not terminated;
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Signed by the adopting parent(s) indicating they are aware of any unresolved legal issues
regarding termination of parental rights;
o Medical at risk statement.
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If the child is identified as having a specific special need or exposure to a specific substance in
utero the adoptive resource needs to sign an medical risk addressing the specific concern.
o Current adoptive home study or approval;
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Done under the receiving state’s law, including child abuse and law enforcement clearances;
If an out of state clearance is needed, then an interpretation letter is also required from ChildLine.
o Affidavit of Identification
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From the birth mother identifying all possible fathers;
o Certification that the consents are in compliance with the applicable laws of the sending
state or where requested by the receiving state. Done by:
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A licensed attorney; or
Authorized agent of a private adoption agency; or
Appropriate independent entity.
o Statement of authority to place child when an agency is placing the child. Can be:
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A court order; or
Custody statement; or
Similar binding statement showing basis of the agency authority.
CYS Agencies need to include:
 Regulation 2 Statement*;
 Current Court Order showing:
 Goal change to Adoption; or
 TPR (depending on receiving state).
 Current service plan; and
 Financial/Medical Plan.
CYS agencies, for already approved ICPC foster placements, many states won’t require
duplicates of most forms from the foster care request in the adoptive request.
Any forms listed above marked with an * were included in the additional handouts. Please
remember:
 The 100A and 100B are mandated forms and cannot be altered.
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 The jurisdictional waiver and Regulation 2 statement are examples, these can be
altered to suit an agencies needs so long as none of the included information is deleted.