(Name) County Children’s Division

(Address)

Town, City Address, Zip Code

To Whom It May Concern:

Attached are the CD-174 and all supporting documentation for an out of county home assessment to be completed on (Name of prospective placement resource). The following children are currently under the jurisdiction of (County) Juvenile Court and in the legal custody of (County) Children’s Division. Recently, (Family) came forward and requested to be considered as a possible placement resource for this child/ren.

This family is involved with Children’s Division due (reason for involvement).

This family will need to be (licensed/ not need to be licensed). These children are Title IVE eligible. (include here a summary of any special needs ie counseling, medical etc.)

If you have any questions, please do not hesitate to contact me by email at (worker's email address) or (xxx-xxx-xxxx) . My supervisor is (name) . Her/His email is (supervisor's email address) and his/her phone number is (xxx-xxx-xxxx)

Sincerely,

(Name)

(Title)

(County) Children’s Division.

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