Inmate Personal Funds Withdrawal Slip

Date: Voucher Number: HQ
Balance Before Draw: Facility/Housing Unit:
Inmate Trust Account Withdrawal Details
Key
Description
Qty
Per
Total Price
Key
Description
Qty
Per
Total Price














































































Please charge to my inmate trust account the sum of
$

I authorized the amount charged to be paid to:

(Payee) (Street Address)

(City, State, and Zip Code) (For the Purpose of)

(Inmate’s Printed Name) (Inmate’s Signature) (Inmate’s IDOC Number)

The inmate’s trust account has been charged in the amount authorized:
(Approving Official’s Signature and Associate ID Number)
Pink copy (inmate maintains)
Original and Yellow copy to approving official (after completing, yellow copy returned to inmate)

This is an exact model and must be produced on three (3)-part NCR paper.