Emergency Contact Information Form (Offender)

IDAHO DEPARTMENT OF CORRECTION
Emergency Contact Information Form (Offender)
In the case of a medical emergency or death, the Idaho Department of Correction (IDOC)will make
notifications based on the information you provide on this form. IDOC will begin with the primary and then
secondary contacts. Once IDOC has made contact with one of your emergency contacts, no further contacts
will be made. It is up to the person contacted to contact the remainder of your family or friends. If no one
listed on this form can be contacted, IDOC will attempt to locate your next of kin or an approved visitor.
Periodically, IDOC will ask you to complete a new Emergency Contact Information Form to ensure your
primary and secondary contact information remains up-to-date. However, it is your ultimate responsibility to
update the information you provide on this form should there be changes.
Primary Contact:
Name: Relationship:
Address (physical):
Address (mail):
Home phone: Cell phone: Work phone:
Secondary Contact#1:
Name: Relationship:
Address (physical):
Address (mail):
Home phone: Cell phone: Work phone:
Secondary Contact#2:
Name: Relationship:
Address (physical):
Address (mail):
Home phone: Cell phone: Work phone:
Property Disposal Information:
In the event of my death, I name the following individual or charitable organization (limited to one
designation)to receive my property and any remaining money I have left in my Offender Trust Account after
all expenses have been settled. Any remaining money will be mailed to the designated individual or
charitable organization in accordance with SOP 114.03.03.011, Offender Trust Account.
Name: Relationship:
Address (physical):
Address (mail):
Home phone: Cell phone: Work phone:
Offender Name: IDOC Number:
(print)
Offender signature: Date:
Witness
Name: Associate (employee)#:
(print)
Witness signature: Date:
Property(Non-money) Pick Up Signature: Date:
Distribution: Original to central file; Copy to offender
(updated 12/2/2014)