SOP 406.19-att-3: Indigent Legal Supplies Request Form

SOP 406.19

Attachment 3

7/1/20

INDIGENT LEGAL SUPPLIES REQUEST FORM
(This form shall be maintained in the Offender Reference Library)

Offender Name: ___________________________________________Date: ____________________________

GDC I.D. No.____________________________ Building/Room Assignment No.________________

I am declaring that I am indigent. I am requesting that stationery items be provided to prepare privileged/legal mail. I
understand that, if funds are received in my account, I will be charged the current cost for these supplies and
authorize the Business Office to deduct funds from my account when such funds are available.

___________________________________________ __________________________________________
Offender’s Signature Date Supplies are needed

To: Business Office

The above named offender has requested stationery to prepare privileged/legal documentation. Please advise me,
by phone, if this offender is declared indigent.

Is offender indigent? Yes _______ No _______ Date _________________________

TO: Business Office FROM: Legal Library

The above named offender received the following supplies:

WEEKLY AUTHORIZED AMOUNT AMOUNT RECEIVED PRICES

Carbon Paper, Sheets 5 5 Carbon @ $ .10
Typing Paper, Sheets 20 20 Typing Paper @ .01
Pen, Monthly, exchange 1 1 Pen @ .10
Envelopes, 10" x 13" ____ ____Envelopes @ .16
Envelopes, # 10 ____ ____Envelopes @ .02

Total: $_______

__________________________ __________________________
Received By (Offender’s Name) Issued By

_____________
Date Received

Offender Account Check No. Paid Amount

Written Off Date Amount

Retention Schedule: Upon completion, this form shall be retained locally for three (3) years and then destroyed.