SOP 406.19-att-4: Indigent Non-Legal Supplies Request Form

SOP 406.19
Attachment 4

7/1/20

INDIGENT NON-LEGAL SUPPLIES REQUEST FORM

Offender Name: ___________________________________________Date: ____________________________

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

I am declaring that I am indigent. I am requesting that stationery items be provided in order to maintain community
ties. 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 supplies.

Is offender indigent? Yes _______ No _______ Date _________________________

The above named offender received the following supplies:

WEEKLY AUTHORIZED AMOUNT AMOUNT RECEIVED COST

6 Writing Paper, Sheets @ $0.01 ea. __________________ $________

3 Envelopes, @$0.02 __________________ $________

1 ea. Pen Monthly @ $0.10 __________________ $________

TOTAL $________

________________________________ ___________________
Offender’s Signature Issued By

____________
Date Received

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