DUNIT
Form.DC-135A

Commonwealth of Pennsylvania
Department of Corrections

INMATE'S REQUEST TO STAFF MEMBER
INSTRUCTIONS
Complete items number 1-8. If you follow instructions in
preparing your request, it can be responded to more
promptly and inlelliaently.
1. To: (Name and Title of Officer)

2. Date:

3~ By:" (Print Inmate Name and Number)
,

4.

Counselor's Name:

5.

Unit Manager's Name:

7.

Housing Assignment

..

Inmat. SiQnalu,.

6.

Work Assignment

8.

Subject: Slale your request completely but briefly. Giye details.

..

..

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STAFFMEMBERNAME

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DATE
Signature

7.2.1, Counseling. Services Procedures Manual- Section 3, Request Slips

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Attachment 3-A

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INMATE SUBSCRIBER AGREEMENT

INMATE NA.,E:

,Housing Unit:

Department.,.:

_

1. r understand that this ·'nmate Subscriber Agreemenr sets forth the te.rms and canadions by which I
may subscribe to cable television.

2. Junderstand that·this ·'nmate Subscriber Agreemenr is NOT a contract between myself and the
Department of CorrectionS.
'
3. I understand that when' I sign this ·'nmate Subscriber Agreement,II I am agre~ing to ,do everything this
document states" must do.
4. I understand. the Cable Service ~rovider will sell cable television serVice to me for a monthly fee.
.
. '5. I understand the Cable Service Provider is not required to sell me cable televisIOn service unlesS I
have paid for the service in advance.
.
.
,

6. I authoriZe the Department of Corrections to automatically deduct the cable television service fee
from my Inmate account every month In advance of the month for which I am purchasing cable
television service, and to send the fee to the Cable Service Provider.

. '

7. I understand that I pay the monthly fee established to have my television connected to one live -sIngle
outlet for cable 8ervIce. I understand that the Cable Service Provider may change the monthlyfee
upon thIrty (30) days' noUficatfon.

, B. I undeistand that I must notify the Department of Corrections In writing accOrding to poncy .
(CanceUatJon of cable Service'- Attachment 1-8), to' cancel service or the deductions will contInue.
Including de~uctions when the monthly fee is Increased, whether ~r not Jwant to cOntinue p~ying for
cable teJevJslon services. cancellations must be received by the facirlty Inmate Accounting Office, no
~ than 1he 15" day, ofthe month prior to cancelation. Cable service win Jhen be canceled o.n the
first day of the next month or next regular working day.' .
'

9. I understand the Cable ServIce,ProvIder win .cancel my ~ble t~levislon ServIce a~ the end of the. PaId
month if I notify ~ Deparbnent of Corrections to st9P deducUng the monthly fee for' cable television
services.

10. I understand the cable Service Provider wJ1l canCel my cable televisIon service at the 'end of the paid
month ffthere Is not enough money In my-Inmate account to,pay the next n:aonth's fee when due~ .
11. I ,understand that in the event of a move or change of my location within the facility, the .Department
. .of Corre~fons or the Cable Servfce Provider has up to three (3) business days to change, the cable
connection to my new location.
'

12. I understand th~ .upon canceDation'of my cable service for any reason, I will be subjected to a
waiting period of two service months until a new agreement can be submitted for cable televisIon
'. service.
13. J understanCI that·' am not entiUed to a full or partial refund for cable television service when service Is
cancelled for any reason or when J am absent from the faclfity for ATA, furlough, h~spltaf stay. etc. J
may be entitled to a ptlHat~ refund for an Interruption In service caused by the cable Service
DC}-ADM 002, Inmate Cable Television Service Procedures Manual
Section 1- Responslbll1t/es

Attachment 1·A

,

Provider only if a pro-rated refund is required under the agreement between the Cable Service
Provider and the Deparbnent of Corrections.
' .
14. I understand and accept personal responsibility for that portion of the cable provider's equipment that
is loCated in my assigned living quarters and conne~ed to my television. The Cable Service Provider
may terminate cable television service immediately If the cable television equipment I~ed in my
assigned flVing quarters or connected to my television Is damaged or tampered. I Will pay the cost of
repairing or replacing the damaged cable television·equipment located in my assigned living quarters .
and connected to my television. I authorize the Deparbnent of Corrections·to·deduct this cost·from.
my Inmate cash account for payments to the Cable service Provider. I understand that the Cable' .
. Service Provider shaD not be required to restore cable service to any inmate subscriber who has
caused damage to the system service of the cable Service provider. .
.
.
15. '1 will connect only one television to each outlet that I pay for~ I underStand that aD other connections
to receive cable television service are unauthorized. Including connection of another television to my
television. I will pay.the ~t of one additional month's fee If any television receives cable teleVision
service from an unauthorized connection to the outlet that I pay for. I will pay this adcfltional Tee even
if I did not give another 'person pennissJon to receive cable television service from the outlet I pay for.
I understand that pennitting .another person .to connect hiSlh.er television to the cable service I receive..
is a aime, 18 Pa.C.S. 39~6 '(Theft of Services). and that paying for the stolen services does ~
. excuse me from criminal prosecution. I understand the cable service Provider may.termlnate cable
television service lrivnedlately in the event of unauthorized connection. I authorize the Department of
CorrectIons to deduct the additional fee for receipt of unauthorized cable television services for
payment to the ~bIe Service ProvIder.
.
. .

16. I' understand the monthly ~ble charge due and payable to tJie Cable Service Prpyjder for Broadband.
Communication services (cable) will not be pro~te(J. .

. 17. I underStand the Cable Service ProvJder Is not responsible for an technical diffJculties In recepUon
experienced by any subscriber because of the nature qonditlon of the subscriber's properly
connected television or because of unauthorized alterations to, or connections with. the CabJe
Service Provider's ~ystem at the subscriber's o~t location.

or

18. I understand ttie Cable Service Provi4er 8$S~mes no responsibility for the operatJ~, maintenance, or
repair of television sets not Installed or fumlshed by the cable service Provider, which ·may be
.
conneoled to the Cable.Service Provider's system.
19. I understand the cable Service Provider Is the owner of the cable television.service equipment. I
understand that this.agreement does not sell or rent to me any equipment owned by the cable
Service Provider. I am purchasing cable television service only.
."

I have read all the above statements and the Cable TV Policy or they have been read to me. I
agree to abide by' every statement made In this agreement and understand I am legally bound by
this d o c u m e n t . .
.
SIGNATURES

INMATE

DATE

EMPLOYEE WITNESS

DATE

DC-ADM 002. Inmate cable Television Service Procedures Manual
.Section 1- Responsibilities

. . .. ... ...

Attachment 1·A

.

VOLUNTARY REQUEST TO CHANGE CELL PARTNERS

Current Tier and Cell

Name and Number

Are you amenffy assgned boUom bunk and/or boU~ tier? YES

NO

Current TIer and Cell

Name and Number

Ale you cuaentty assfgned boUom bctnlc andfor bottom tier? YES

NO

NOTE:
•• Both Inmates must sign and tum In this fonn In the prese~ or the Unit Officer··

Inmate's Signature (Name & Number)
6-2 Pod·Officer

Inmate's Signature' (Name & -Number)

Comments:

DYesDNo

_

Signature:
6-2SgL

DY.esO No

.Comments:

----'-----------

Comrnents:

-------

$lgnature: .
2.10Poci~

DYes 0 No

Signature: -.
2-10SgL

Commenls:

DYesDNo

_

Signature:
CoUnselor (If avaIlable) D Yes D ~o

. Sfgnalure:

Unit Manager

COmments:

~---

_

Comments:

DYes 0 No

Signature:

Start date: _ - - - -

_

_

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End date: __'_ _....:.-

_ Cell:

--~----

All Cell Agreements must be processed and signed by all staff list~ above unless otherwise noted.

SUPPLEMENTARY AUTHORIZED INMATE TELEPHONE NUMBERS
Commonwealth of Pennsylvania - Department of Corrections
I Inmate Name:
I Housing UnitlCell#:
I Inmate#:
IPIN#:
1. REMOVAL FROM LIST OF AUTHORIZED INMATE TELEPHONE NUMBERS
Relationship
Telephone #
Address
Name

2. ADDITIONS TO LIST OF AUTHORIZED INMATE TELEPHONE NUMBERS
Relationship
Telephone #
Name

3. All Approved:

I Date:
Date of Birth

Address

Date of Birth

All Approved Except:

Any telephone call, which you make or receive in any state correctional facility, may be intercepted, recorded, monitored, or divulged. The Only
exception is properly placed telephone calls to or from your attorney.
Inmate Signature
Remarks:

Approving Signature:

DC-8S
Revised 11/30105

Title:

Date:

SUPPLEMENTARY AUTHORIZED INMATE TELEPHONE NUMBERS
Commonwealth of Pennsylvania - Department of Corrections
IPIN#:
I Inmate Name:
I Housinq UnitlCell#:
I Inmate #:
1. REMOVAL FROM LIST OF AUTHORIZED INMATE TELEPHONE NUMBERS
Name
Relationship
Telephone #
Address

2. ADDITIONS TO LIST OF AUTHORIZED INMATE TELEPHONE NUMBERS
Name
Relationship
Telephone #

I Date:
Date of Birth

Address

Date of Birth

\

3. All Approved:

All Approved Except:

Any telephone call, which you make or receive in any state correctional facility, may be intercepted, recorded, monitored, or divulged. The Only
exception is properly placed telephone calls to or from your attorney.
Inmate Signature
Remarks:

Approving Signature:

DC-8B
Revised 11/30/05

Tille:

Date:

SUPPLEMENTARY AUTHORIZED INMATE TELEPHONE NUMBERS
Commonwealth of Pennsylvania - Department of Corrections
I Housinq Unit/Cell#:
I Inmate Name:
I Inmate #:
IPIN#:
1. REMOVAL FROM LIST OF AUTHORIZED INMATE TELEPHONE NUMBERS
Relationship
Telephone #
Address
Name

2. ADDITIONS TO LIST OF AUTHORIZED INMATE TELEPHONE NUMBERS
Telephone #
Relationship
Name

3. All Approved:

I Date:
Date of Birth

Address

Date of Birth

All Approved Except:

Any telephone call, which you make or receive in any state correctional facility, may be intercepted, recorded, monitored, or divulged. The Only
exception is properly placed telephone calls to or from your attorney.
Inmate Signature
Remarks:

Approving Signature:

DC-8B
Revised 11/30105

Title:

Date: