Form DOC06-073 "Request for Advance and Promissory Note" - Washington

What Is Form DOC06-073?

This is a legal form that was released by the Washington State Department of Corrections - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 3, 2020;
  • The latest edition provided by the Washington State Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOC06-073 by clicking the link below or browse more documents and templates provided by the Washington State Department of Corrections.

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Download Form DOC06-073 "Request for Advance and Promissory Note" - Washington

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REQUEST FOR ADVANCE AND PROMISSORY NOTE
Name
DOC number
Date
I hereby request the Department to grant an advance without interest in the amount of $
from the Community Services Revolving Fund (CSRF). The following financial information is supplied
for establishing my eligibility for the advance:
A. Outstanding CSRF debts
$
B. Amount of request
$
C. Total debts to CSRF
$
I understand that if the advance is approved, the proceeds will be deposited into my trust account and
disbursed per RCW 72.65.090. If the Department grants my request, I promise to pay the amount of
the advance secured by this note. I grant the right to the Department to make payments on this note
from my trust account.
I certify that the above information is true and complete and submitted for the purpose of obtaining an
advance from the CSRF.
Signature
Date
CASE MANAGER RECOMMENDATION
This individual will be housed at Work/Training Release until
.
I have reviewed this application and recommend this request be:
Approved
Denied
Reason for denial:
Name
Signature
Date
DECISION
Approved
Denied
Name
Signature
Date
Approval is required by the Work Release Administrator if line “C” is more than $300.00.
Approved
Denied
Work Release Administrator
Signature
Date
BUSINESS OFFICE USE ONLY
Date issued:
Check number:
Amount: $
The contents of this document may be eligible for public disclosure. Social Security Numbers are considered confidential information and
will be redacted in the event of such a request. This form is governed by Executive Order 16-01, RCW 42.56, and RCW 40.14.
Distribution: WHITE - Business office
CANARY - Work/Training Release facility
PINK - Incarcerated individual
DOC 06-073 (Rev. 03/03/20)
Page 1 of 1
DOC 200.000
Scan Code TA03
REQUEST FOR ADVANCE AND PROMISSORY NOTE
Name
DOC number
Date
I hereby request the Department to grant an advance without interest in the amount of $
from the Community Services Revolving Fund (CSRF). The following financial information is supplied
for establishing my eligibility for the advance:
A. Outstanding CSRF debts
$
B. Amount of request
$
C. Total debts to CSRF
$
I understand that if the advance is approved, the proceeds will be deposited into my trust account and
disbursed per RCW 72.65.090. If the Department grants my request, I promise to pay the amount of
the advance secured by this note. I grant the right to the Department to make payments on this note
from my trust account.
I certify that the above information is true and complete and submitted for the purpose of obtaining an
advance from the CSRF.
Signature
Date
CASE MANAGER RECOMMENDATION
This individual will be housed at Work/Training Release until
.
I have reviewed this application and recommend this request be:
Approved
Denied
Reason for denial:
Name
Signature
Date
DECISION
Approved
Denied
Name
Signature
Date
Approval is required by the Work Release Administrator if line “C” is more than $300.00.
Approved
Denied
Work Release Administrator
Signature
Date
BUSINESS OFFICE USE ONLY
Date issued:
Check number:
Amount: $
The contents of this document may be eligible for public disclosure. Social Security Numbers are considered confidential information and
will be redacted in the event of such a request. This form is governed by Executive Order 16-01, RCW 42.56, and RCW 40.14.
Distribution: WHITE - Business office
CANARY - Work/Training Release facility
PINK - Incarcerated individual
DOC 06-073 (Rev. 03/03/20)
Page 1 of 1
DOC 200.000
Scan Code TA03