SOP_NUMBER: 406.19-att-1
TITLE: Offender Miscellaneous Withdrawal Form
DIVISION: Administrative & Finance
TOPIC_AREA: 406 Policy-Administration and Finance
EFFECTIVE_DATE: 2020-07-01
WORD_COUNT: 199
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105149
URL: https://gps.press/sop-data/406.19-att-1/

SUMMARY:
This form is used when incarcerated individuals request to withdraw money from their institutional account for miscellaneous purposes. The form requires documentation of the amount requested, reason for withdrawal, mailing address, and includes approval chains based on withdrawal amount thresholds ($150 and $500). Approvals are required from facility staff, wardens, and administrative directors depending on the amount being withdrawn.

KEY_TOPICS: offender account withdrawal, inmate account, miscellaneous withdrawal, financial request, institutional account, approval authority, warden approval, store restriction, indigent loan, stamp cost, envelope cost

ATTACHMENTS:
  1. Offender Miscellaneous Withdrawal Form
     URL: https://gps.press/sop-data/406.19-att-1/
  2. Request for Indigent Postage
     URL: https://gps.press/sop-data/406.19-att-2/
  3. Indigent Legal Supplies Request Form
     URL: https://gps.press/sop-data/406.19-att-3/
  4. Indigent Non-Legal Supplies Request Form
     URL: https://gps.press/sop-data/406.19-att-4/
  5. JPAY Release Card Request Form
     URL: https://gps.press/sop-data/406.19-att-5/
  6. JPAY Release Card Receipt Confirmation Form
     URL: https://gps.press/sop-data/406.19-att-6/

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FULL TEXT:
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# 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.