SOP 406.19-att-1: Offender Miscellaneous Withdrawal Form

# Offender Miscellaneous Withdrawal Form

SOP 406.19
Attachment 1

7/1/20

Request Date: ________________________________ GDC #: __________________________________________

Offender Name: ____________________________________________________________________________________

Facility: _____________________________________ Dorm/Room#:_____________________________________

Quarter: January–March April-June July–September October–December

Requested Withdrawal Amount: $______________________________ (If this amount is over $150 it will require the
Warden’s signature and if amount is over $500 it will require Administration Division Director approval and signature .)

Reason for Withdrawal:
__________________________________________________________________________________________________

__________________________________________________________________________________________________

Send Check to:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

I understand the above amount will be withdrawn from my account. I also understand that the cost of an envelope and a
stamp will be withdrawn from my account, as I no longer provide this with the request. This withdrawal will show on my
account as an Indigent Loan and will be for the current cost of $0.55.

Date: __________________________ Offender Signature: ________________________________________________

I certify that the signature and GDC# of the above named offender is correct:

Date Approved/Dis-approved: _________________ Signature of authorized approver: ___________________________

Printed name of approver: ____________________________________________________________________________

Required: Store Restriction: Yes No

Date Approved: _________________ DWA/Authorized Designee: ___________________________________________

Required if requested amount is over $150.00:

Date Approved: _________________ Warden’s Signature: __________________________________________________

Required if amount is over $500.00:

Date Approved: _________________ Regional Director Signature: ___________________________________________

Date Approved: _________________ Assistant Commissioner of Admin. Signature: _____________________________

Retention Schedule: Upon completion, this form shall be scanned and maintained electronically for five (5) years on the
CBU server.