Visit List Verification

(to be completed by the inmate or applicant)

Inmate Name:	Inmate #:	Unit:	Cell #:
The following immediate family members may be eligible to be placed on an inmate’s visit list. All visitors are subject to a criminal history background check. Visitors who are approved for placement on an inmate’s visit list are subject to annual background checks conducted by DOC staff.
Spouse	Sister	Grandchild	Grandparent	Son-in-law	Legal Guardian
AA Sponsor
Child	Step-brother	Step-parent	Great Grandparent	Daughter-in-law	Friend (2 allowed) **
Parent	Step-sister	Half-sister	Mother-in-law	Sister-in-law *	Attorney of Record
Brother	Step-child	Half-brother	Father-in-law	Brother-in-law *	M-2/W-2 Sponsors

* Spouse of the inmate’s brother or sister ** Two (2) friends who are at least eighteen (18) years of age and not immediate family members or two (2) nieces/nephews of any age may be approved for an inmate’s visit list.

Applicants must provide complete information. Aliases or nicknames will not be accepted. P.O. boxes are not accepted for a “physical address”. Social Security numbers must be provided for the purpose of conducting a criminal background check. Applications containing incomplete information will not be considered. Please print clearly.
Full Name

& Gender	Relationship

to Inmate	Date

of Birth	Soc.

Security #	Drv. Lic # &

State of Issue	Physical Address

(city, county, state & zip code	Telephone

Number	Approved

or Denied
1.
Male Female
2.
Male Female
3.
Male Female
4.
Male Female
5.
Male Female
6.
Male Female
7.
Male Female

Staff Name	Staff Unit

Date:
NOTE:

Applicants may choose to mail/deliver the completed form directly to the facility. All information provided shall remain confidential and will not be shared with inmates.

Revised: 03/27/2013	Page 1 of 2

Operations Memorandum

COPR12956

2015-04-15

COPR12548

State of South Dakota