FORM IA/VI 

(Receiving State) 

           

 
,  hereby apply for supervision as a parolee or probationer to the Interstate 
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.   

 

(Sending State) 

n view of the above, I do hereby apply for permission to be supervised on 

parole  

probation in 

           

. 

(Receiving State) 

 

MEMORANDUM OF UNDERSTANDING AND WAIVER 

           

, 

realize that the grant of  
           

to go to the State of 

parole  

probation and especially the privilege to 

is a benefit to me.   

 
FORM VI 
 
I, 
eave the State of 

 
           

 
 

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herefore, I promise: 

.  That I will make my home with             

 
until a change of residence is authorized by the proper authorities in the receiving state. 
 

(Name, Relationship, and Address) 

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 

 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) 

ermission is hereby granted to the above-named juvenile to apply for, reside in, and be supervised by the State of  

                     
        (Receiving State)    
  

provided that the receiving state accepts supervision. 
 

 

 

(Date) 

SIGNED: 

(If probation, sending state’s JUDGE;         If parole, sending state‘s COMPACT OFFICIAL) 

 

state.   

 

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                        INTERSTATE COMPACT FOR JUVENILES 

                             APPLICATION FOR SERVICES AND WAIVER 

                                         

 

 

 

APPLICATION FOR COMPACT SERVICES 

FROM: 

           

           
 

 
Form IA 

O: 

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  1

 

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CJ 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. 

orm IA – Application for Compact Services 

eceiving 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. 

orm 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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CJ FORM IA/VI  |  Rev. 02-23-15