Visitation Assistance Fund Request
Please use this form if you need financial support to access either in person or video visits with your loved one. You must be an approved visitor to utilize this fund. Please allow 24-48 hours for a response.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Visitor's Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Name of Incarcerated Individual:
*
First Name
Middle Name
Last Name
Inmate Number:
Inmate Facility:
*
For Which Service Do You Need Financial Assistance?
*
Please Select
Video Visitation
VADOC Face-to-Face Visit
Please provide the details of your need below.
Submit
Should be Empty: