INTERSTATE COMPACT FOR JUVENILES 

 

 

 

FORM V 

                               REPORT OF SENDING STATE UPON PAROLEE OR PROBATIONER 
                            BEING SENT TO THE RECEIVING STATE 

 will depart OR  

 has departed from sending state by 

           

and was instructed to report  

 in person  

 by telephone  OR  

           
(Race) 

           
(Sex) 

(Mode of Transportation) 

 by letter, within 48 hours of 
 

 
 

DATE: 
 

           
 

           
(County) 

           
(Date of Birth) 

Telephone: 

                

O: 

           

(Receiving State) 

FROM: 
 

           

(Sending State) 

 

           

(Name of Juvenile) 

RE: 
 
 
The above-named juvenile 
 

 

 

(Date) 
 
arrival in the receiving state to: 

           

n 

  o

ame: 

           

ddress: 
 

           

(Street Address) 

           

(City) 

 

 

 

 

 

 

 

 

 

 

 

           

(State) 
 

 

           

(Zip) 

nclosed please find: (please check applicable items) 

 Parole or probation sanctions 

 Other material as follows: 

Signed: 

 

Title: 

           

Agency: 

           

 

ICJ FORM V  |  Rev. 01-01-11  

   

 

 

   

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INSTRUCTIONS FOR COMPLETING ICJ FORM V 

PLEASE TYPE OR PRINT LEGIBLY. 

hen 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. 

ule 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.                                        

eceiving 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. 

 
 

 

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