VOID

Scott Walker
Governor

Gary H. Hamblin
Secretary

Mailing Address:
Attention Visitor Processing
WSPF
1101 Morrison Drive
Boscobel, WI 53805-1900

State of Wisconsin
Department of Corrections

PRINT LEGIBLY

OFFENDER JAMES TERRY
DOC NUMBER 13739861
INSTITUTION/CENTER NAME WSPF
LIVING CENTER/UNIT E-220

OFFENDER SIGNATURE James Terry
DATE SIGNED 10/11

Proposed Visitor - Please Read This Section:

- If you wish to visit with this offender, fully complete the reverse side of this questionnaire. The offender will notify you when the processing of this form has been completed. If you do not wish to visit, please disregard this form.

- Each visitor, including minors, is required to submit a separate DOC-21AA Visitor Questionnaire.

- All questions and check boxes on the reverse side of this form must be answered completely and accurately. Falsified or incorrect information may result in denial of visitation. If form is incomplete or illegible, it will not be processed and will be destroyed.

- If the proposed visitor named on this form is a minor, the legal, non-incarcerated guardian/custodial parent of the minor listed must sign the form.

- All approved minor visitors must be accompanied by an approved non-incarcerated adult that is listed on the offender's approved visiting list.

- This form must be mailed to the address listed above. If this form is given or mailed directly to the offender, it will NOT be processed and will be destroyed.

- If you are approved for visiting and are over the age of 16, you will be required to show photo identification upon arrival at the institution. Only the following forms of VALID identification will be accepted.

- State Drivers License
- Military/Tribal Identification Card
- Department of Transportation Picture Identification Card
- Passport/Visa

DEPARTMENT OF CORRECTIONS
Division of Adult Institutions
DOC-21AA (Rev. 1/2011)

DEPARTMENT OF CORRECTIONS
Division of Adult Institutions
DOC-21AA (Rev. 1/2011)

WISCONSIN
Administrative Code
Chapter DOC 309

Print or Type the Information

VISITOR QUESTIONNAIRE

PRINT LEGIBLY FIRST NAME MIDDLE NAME LAST NAME DATE OF BIRTH PHONE NUMBER (Include Area Code) SEX
M F

OTHER NAMES YOU ARE USING OR HAVE BEEN KNOWN BY, INCLUDING MAIDEN NAMES (Write NONE if None)

STREET ADDRESS (Include Apt. # or Lot #) CITY STATE ZIP CODE

WHAT RELATIONSHIP ARE YOU TO THE OFFENDER - BE SPECIFIC (e.g. Father, Mother, Brother, Sister, Stepfather, Stepmother, Friend)

ARE YOU A VICTIM OF THE OFFENDER'S CURRENT OR PAST OFFENSES
NO YES

Did you first meet this offender while he/she was incarcerated?
NO YES

IF YES, PLEASE DESCRIBE IN DETAIL HOW AND WHERE YOU MET

HAVE YOU EVER BEEN DENIED, RESTRICTED, OR REMOVED FROM ANY OFFENDER'S VISITING LIST IN THE PAST
NO YES

IF YES, WHY (Use Additional Sheets if Necessary)

WHAT INSTITUTION/CENTER WHEN

HAVE YOU EVER BEEN IN JAIL OR PRISON
NO YES

IF YES, WHY, WHERE AND WHEN (List All - Use Additional Sheets if Necessary)

HAVE YOU EVER BEEN ON PROBATION, PAROLE, EXTENDED OR INTENSIVE SUPERVISION
(If yes, why, where and when. List Every Occurrence Attach Additional Sheets If Necessary)
NO YES

DO YOU HAVE ANY CRIMINAL CHARGES PENDING
NO YES

IF YES, WHERE

WHAT ARE THE CHARGES (List Every Occurrence. Attach Additional Sheets If Necessary)

HAVE YOU EVER BEEN A VOLUNTEER OR EMPLOYED BY ANY DOC FACILITY OR DOC CONTRACTED AGENCY
NO YES

WHAT FACILITY/AGENCY

WHEN

DO YOU HAVE A DISABILITY OR MEDICAL CONDITION THAT REQUIRES AN ACCOMMODATION IN ORDER FOR YOU TO VISIT
NO YES - IF YES, YOU WILL RECEIVE FORM DOC-2424 "VISITOR REQUESTING ACCOMMODATIONS" WHICH MUST BE COMPLETED AND RETURNED PRIOR TO VISITING.

THIS FORM MUST BE SIGNED BY THE PROPOSED VISITOR, OR IF THE PROPOSED VISITOR IS A MINOR (under age 18), FORM MUST BE SIGNED BY CHILD'S LEGAL, NON-INCARCERATED GUARDIAN/CUSTODIAL PARENT.

I hereby declare the above statements are true and I understand that providing incorrect information could result in a denial of visiting privileges. I further agree to comply with all policies and guidelines that I have received with this questionnaire.

I hereby declare that I am the non-incarcerated parent or legal guardian of the minor named above and that I hereby give my approval for him/her to visit the offender named on the reverse side of this questionnaire.

SIGNATURE of proposed visitor, or if proposed visitor is a minor (under age 18), form must be signed by child's legal, non-incarcerated guardian/custodial parent.

Must be Signed

PRINT NAME

DATE SIGNED

PROCEDURE INITIALS DATE COMPLETED COMMENTS
ETIME, CIB/NCIC,
Portal 100
WICS
PSI
FILE
CCAP

NAME DATE
APPROVED
DENIED

*If denied, a DOC-161 and a chronological recording must be attached with detailed explanation and WI Administrative Code 309 referenced.

DISTRIBUTION: Original - Social Service File