Douglas County Jail Inmate Form – Fill Out and Use This PDF

Douglas 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

710South 17th Street Omaha NE 68102

________________________________________________ ____________________ __________________________

Inmate’s NameData NumberHousing 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.

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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 NameFirst NameMiddle 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

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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