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Get CA CDCR 2234 2012

STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION ACP APPLICATION AND VOLUNTARY AGREEMENT CDCR 2234 07/12 The Alternative Custody Program ACP is a voluntary program that promotes parenting family reunification and the development of life skills while addressing treatment needs. The ACP allows inmates to be housed in a personal residence a transitional care facility or a residential drug or treatment program instead of serving time in prison* I understand placement into the ACP is based upon meeting specific eligibility criteria and the California Department of Corrections and Rehabilitation has the authority for final placement approval based on bed availability and other factors. While participating in the ACP I will be subject to applicable rules and regulations governing inmates pursuant to the California Code of Regulations CCR Title 15 Division 3. I understand I may be removed from the ACP and returned to prison to serve the remainder of my original sentence for any reason with or without cause. I. TO BE COMPLETED BY INMATE I meet the criteria set forth in the CCR Title 15 section 3078. 2 including the following Check all that apply I am a female Select one I have private medical insurance. I agree to apply for any county state or federal medical coverage for which I may qualify. OR I request to reside at the following location Private Residence Include street address city county and zip code My private residence is located at I understand my residence must have no aggressive animals no weapons unobstructed access by law enforcement and will be verified by a Parole Agent. The contact person at the above address is My relationship to the contact person is Residential Drug or Treatment Program or Transitional Care Facility I understand that my signature on this document indicates my willingness to voluntarily participate in the ACP. CDC NUMBER INMATE NAME PRINTED INMATE SIGNATURE DATE SIGNED HOUSING UNIT II. FOR USE BY INSTITUTION COUNSELING STAFF Does the participant have a qualifying disability requiring effective communication Yes No If yes cite the source document and/or observation s What type of accommodation/assistance was provided to achieve effective communication to the best of the inmate s ability COUNTY OF LAST LEGAL RESIDENCE INMATE ELIGIBLE COUNTY OF COMMITMENT INSTITUTION EPRD REASON IF INELIGIBLE CORRECTIONAL COUNSELOR NAME PRINT PHONE NUMBER III. FOR USE BY ACP PROGRAM MANAGER ACP PROGRAM NAME ASSIGNED PAROLE UNIT IV. FOR USE BY PAROLE UNIT DISTRICT/UNIT RECEIVING AGENT ASSIGNED TO INVESTIGATE DATE DUE COMMENTS AGENT S RECOMMENDATION Proposed residence meets criteria PAROLE AGENT NAME PRINT PAROLE AGENT SIGNATURE UNIT SUPERVISOR APPROVAL Concur with agent s recommendation UPON COMPLETION OF PRIVATE RESIDENCE VERIFICATION - RETURN THIS FORM TO THE SENDING INSTITUTION C PR OFFICE EPRD means Earliest Possible Release Date Distribution Original to c-file copy to inmate. The ACP allows inmates to be housed in a personal residence a transitional care facility or a residential drug or treatment program instead of serving time in prison* I understand placement into the ACP is based upon meeting specific eligibility criteria and the California Department of Corrections and Rehabilitation has the authority for final placement approval based on bed availability and other factors. While participating in the ACP I will be subject to applicable rules and regulations governing inmates pursuant to the California Code of Regulations CCR Title 15 Division 3. .

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