SOP_NUMBER: 406.19-att-4
TITLE: Indigent Non-Legal Supplies Request Form
WORD_COUNT: 144
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/337685
URL: https://gps.press/sop-data/406.19-att-4/

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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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.