Inmate Visitation Request Form
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1Douglas County Department of Corrections
Inmate Visitation Request Form
ATTENTION: This form will not be process if mailed to the inmate. No faxes will be accepted.
Mail or hand deliver to:
Douglas County Department of Corrections
th
710 South 17
Street
Omaha NE 68102
________________________________________________ ____________________ __________________________
Inmate’s Name
Data Number
Housing Unit
Persons under eighteen (18) years of age must be on the approved visiting list and accompanied by parent/legal guardian who
is also approved on the inmate’ s visitation list.
---------------------------------------------------------------------------------------------------------------------------------------------------
THIS SECTION IS TO BE COMPLETED BY THE VISITOR AND NOT BY THE INMATE.
Please print clearly or type all information requested.
Full Legal Name ____________________________________________________________________________________
Last Name
First Name
Middle Initial
Current Address ____________________________________________________________________________________
Street/P.O. Box/Rural Route
City
State
Zip Code
Telephone Number _______________ Date of Birth _______________ Sex _______________ Race ________________
Social Security No. __________________________________ Marital Status ___________________________________
Relationship to Inmate:
______________________________
Have you been convicted of a crime other than a traffic violation:
Yes
No If yes, what was date and the offense?
(date)_______________(offense)_______________________________________________________________________
Information provided above may be used to complete a National Crime Information Center background check.
I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND CORRECT TO THE BEST OF MY
KNOWLEDGE. I understand that falsification of this information may result in the denial of visitation privileges.
Applicants Signature: ___________________________________________________ Date: ______________________
NOTE: It is the responsibility of the inmate to notify the visitor concerning the disposition of the request.
XXXXXXXXXXXXXXXXXXX DO NOT REMOVE – FOR FACILITY USE ONLY XXXXXXXXXXXXXXXXXXXXX
__________________________________________________ ____________________ __________________________
Inmate’s Name
Data Number
Housing Unit
__________________________________________________ ____________________ __________________________
Visitor’s Last Name
First Name
Middle Initial
Has been
APPROVED
DENIED to visit. It is the inmate’s responsibility to notify the visitor/applicant of the disposition of
the visiting request. Inmates may submit an Inmate Request Form to the Lobby to remove an approved visitor from their list.
_______________________________________________ ___________________ ______________________________
Staff Signature
Chit Number
Date
White or original: Records Inmate File
Yellow or copy: Inmate
Revised 04/10
DCC 24
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