Personal Withdrawal Request Page 17
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25TENNESSEE DEPARTMENT OF CORRECTION
INMATE FINANCIAL STATUS REPORT
INMATE NAME:
INMATE NUMBER:
SOCIAL SECURITY NUMBER:
INMATE ADDRESS (legal residence)
LAST EMPLOYER:
ADDRESS:
The Inmate Financial Responsibility Act of 1998 (TCA Section 41-21-901 et. seq.) mandates that the
Department of Correction wherein you are sentences may obtain information from you regarding you assets.
“Assets” include property, tangible or intangible, real or personal, belonging to you or due to you including
income or payments from social security, worker’s compensation, pension benefits, previously earned salary or
wages, bonuses, annuities, retirement benefits, insurance benefits, or from any other source whatsoever, but
does not include a homestead owned by you, money received by you from the State of Tennessee as
settlement of a claim against the Department of correction, a money judgment received by you from the State
of Tennessee as the result of a civil action in which the Department of Correction was named defendant and
found to be liable or money saved by you from wages and bonuses paid to you while confined in a state
correctional facility. The State of Tennessee may use this information to seek reimbursement for the rest of
your care. You may be required to update this information during your incarceration. Failure to provide
complete financial information may be considered by the Board of Paroles for purposes of a parole
determination.
I have the following assets:
Dollar Amount
Location (Specify)
Worker’s Compensation/Payments
Retirement Benefits
Other Pension Benefits (Specify)
Previously Earned Salary or Wages
Previously Earned Bonuses
Annuities
Bank Accounts
Stocks or Bonds
Real Property Other than Homestead
Other:
I swear or affirm under oath, that to the best of my knowledge, the information provided herein is complete and accurate.
Inmate Signature
Date
Staff Witness
Date
TO BE COMPLETED IF INMATE REFUSES TO EXECUTE THIS FORM
Staff Comments:
Staff Signature
Date
CR-3561 (Rev. 7-01)
RDA 1100
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