Home Pass Site Inspection Form
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1
2
3
4*For
o ffender:
Name
ICON
N umber
Date
P robation
W ork
R elease
F ederal
S ex
O ffender
Counselor
N ame
*For
C ounselor:
Date
H PI
r eceived
f rom
o ffender:
The
f ollowing
i s
t o
b e
r ead
a nd
c ompleted
b y
y our
f amily/pass
–
s ite
p rospects
Home
P ass-‐Site
I nspection
F orm
( Fort
D es
M oines
t o
C ommunity)
The
above
client
has
identified
you
and
your
residence
as
a
possible
release
residence.
As
our
clients
b egin
t he
h ard
w ork
o f
t ransitioning
f rom
i ncarceration
t o
c ommunity
l iving,
w e
b elieve
it
is
important
that
the
people
they
live
with
be
as
supportive
to
responsible
living
as
possible.
Parolees
and
Probationers
are
prohibited
from
living
in
a
residence
where
there
are
alcoholic
beverages,
i llegal
d rugs,
a nd
f irearms.
P arolees
a re
a lso
p rohibited
f rom
l iving
w ith
p eople
w ho
have
c riminal
r ecords
u nless
a pproved
b y
s upervising
o fficer.
I f
y ou
a re
r enting
y our
r esidence,
it
is
also
important
that
your
landlord
approve
this
arrangement
by
providing
written
documentation
ahead
of
time.
To
assist
our
clients
in
making
a
smooth
transition,
we
ask
you
to
please
complete
this
questionnaire
and
return
to
the
above
named
counselor.
The
Department
of
Correctional
Services
reserves
the
right
to
verify
all
information
provided
on
this
f orm.
PLEASE
NOTE:
An
officer
WILL
NOT
conduct
a
home
placement
visit/investigation
until
this
form
i s
r eceived
a nd
f illed
o ut
c ompletely.
Your
N ame
( Last,
F irst,
M iddle)
Relationship
t o
C lient
Date
o f
B irth
SSN
Phone
Driver’s
L icense
N umber
State
o f
I ssue
Address
( City,
C ounty,
S tate
&
Z ip)
Do
y ou
o wn
t he
r esidence?
Rent?
Y es
N o
Y es
N o
(Convicted
f elons
a re
g eneral
p rohibited
f rom
r esiding
i n
S ection
8
s ubsidized
h ouse)
Are
any
residents
receiving
rent
assistance
(i.e.,
HUD)
that
restricts
who
Y es
N o
may
r eside
a t
s uch
r esidence?
If
rented/leased
property,
print
name
and
phone
number
and
EMAIL
address
of
owner
or
manager
p roperty.
T he
m anager
M UST
p rovide
d ocumentation
o f
a pproval
v ia
a
l etter
o r
e mail
to
offender’s
counselor.
The
letter
must
contain
acknowledgement
of
the
following
information:
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Parent category: Business