Inmate Fee Assessment Form
Use this form to assess inmate-related fees, capture the basis for the assessment, and record review details for each applicable charge.
Inmate Identification
Inmate Full Name
*
First Name
Middle Name
Last Name
Booking / Facility Reference Number
Facility Name / Location
*
Housing Unit / Block
Custody Status
*
Please Select
Pretrial
Sentenced
Holdover
Transitional
Other
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Fee Assessment Details
Fee Category
*
Medical
Property Damage
Disciplinary
Transportation
Administrative
Other
Services or Incidents Triggering the Fee
*
Medical Visit
Medication
Broken Property
Cleaning Supplies
Transportation
Court Appearance
Other
Date of Occurrence
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Fee Frequency
*
Please Select
One-time
Daily
Weekly
Monthly
Per Incident
Other
Estimated Amount (USD)
Responsibility and Review
Fee Responsibility Status
*
Assigned to Inmate
Partially Assigned
Pending Review
Review Factors
*
Rows
Low
Moderate
High
Ability to Pay
1
2
3
Severity
4
5
6
Policy Alignment
7
8
9
Comments / Notes
Reviewer Name and Title
*
First Name
Middle Name
Last Name
Submit Assessment
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