Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Work Release Forms Form. This is a Nebraska form and can be use in 3rd District Local County.
Loading PDF...
Tags: Work Release Forms, Nebraska Local County, 3rd District
LANCASTER COUNTY DISTRICT COURT
APPLICATION FOR
WORK RELEASE
READ ALL INSTRUCTIONS
PRIOR TO STARTING
CFN #_______________________
American LegalNet, Inc.
www.FormsWorkflow.com
LANCASTER COUNTY DISTRICT COURT INSTRUCTIONS
INCOMPLETE FORMS WILL NOT BE PROCESSED AND WILL BE RETURNED TO YOU!
1. Fill out the forms in blue/black ink or typewritten, no pencil or pastel ink.
2. Complete all pages. The judge will not fill any of the Order out for you. You must fill out the entire Order
except for the judge’s signature.
3. List all names of those who will be providing transportation for you. While it is not impossible to have a name
added to the work release Order, it is time consuming. You will be required to fill out a complete set of new
papers, even to change one thing. If providing your own transportation indicate - driving, walking, bicycling or
bus. If not, complete the information for those providing transportation for you.
4. Do not call the judge to ask about the status of your work release. You will be notified in writing
when your sentencing judge has either approved or denied your request.
5. On section #3 of the Application use actual work times only. Do not include release and return times. The
second part of the Application provides for release and return times. Use the same work and travel times when
filling out the Order.
If your sentence is for Contempt of Child Support, fill out:
Section #12 in the application and section #10 in the Order.
If your sentence is for other than Child Support, fill out:
Section #13 on the Application and section #11 on the Order
Violation of this Order and or the law may result in disciplinary action, suspension and or revocation.
Upon completion, submit the forms to Connie Osborn at the jail, they will be sent to Ron Flansburg who will
verify all the information you’ve provided. The forms and findings will be submitted to the sentencing judge. Any
questions about the status of your work release should be directed to:
Ron Flansburg
Connie Osborn
441-8693
441-8902
American LegalNet, Inc.
www.FormsWorkflow.com
READ ALL INSTRUCTIONS PRIOR TO FILLING OUT THIS FORM
APPLICATION FOR RELEASE FROM JAIL
Name ____________________________Social Security # ____________________________________
Nickname or other known name _________________________________________________________
Home Address _______________________________________________________________________
City, State & Zip Code
Phone - Home, Cell & Work
Date of Birth ________________________________________________________________________
District Court C.F.N. #________________________________________________________________
Docket _____________ Page _____________ or CR/CI # ___________________________________
Offense _______________________ Attorney of Record ______________________________________
Judge _________________________Length of Sentence: ______________________________________
Date Defendant will or has started jail sentence ______________________________________________
Currently Housed: Jail ________ or LCF ________
Amend work release by changing:
_____________________________________________________________________________________
Do you have a valid driver’s license?:
Yes _____
No _____
If yes: _______________________________________________________________________________
Driver’s License Number What State
Date License Expires
Name of Employer: ____________________________________________________________________
____________________________________________________________________________________
Address - City, State & Zip Code
Supervisor: __________________________ Work # - Home # - Cell # ___________________________
Employer’s relationship to you, if any: _____________________________________________________
Work Site Location: ___________________________________________________________________
American LegalNet, Inc.
www.FormsWorkflow.com
******************************************************
Investigation submitted to court _________________________ Date _____________________________
Date received by Corrections _____________________________________________________________
Date received by Work Release ___________________________________________________________
_____________________________________________________________________________________
By District Court Work Release Officer
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
IN THE DISTRICT COURT OF LANCASTER COUNTY, NEBRASKA
)
)
)
)
)
)
)
)
)
STATE OF NEBRASKA,
__________________________________
Plaintiff,
vs.
__________________________________
Defendant
1.
2.
Docket _________ Page __________
or
CR/CI # _______________________
APPLICATION FOR WORK RELEASE
Defendant is employed by _____________________________________________________
Employers Name
at: ________________________________________________________________________
Employers Address, City, State & Zip
__________________________________________________________________________
Supervisors name, home #, work #, cell #
Wage of $___________ per _________ paid: weekly bi-weekly monthly (circle one)
Date of next paycheck: _______________________________________________________
__________________________________________________________________________
Address of job site, phone #, work #, cell #
3.
Was defendant employed at time of his/her incarceration? yes
no (circle one)
If yes, where_______________________________________________________________
4.
Defendant requests release as of ____________ from confinement for employment as follows:
Date
Circle am or pm as it applies to start or ending hours.
Monday ________am/pm to_____am/pm
Friday ________am/pm to _______ am/pm
Tuesday ________am/pm to_____am/pm
Saturday ______am/pm to _______ am/pm
Wednesday _____am/pm to_____am/pm
Sunday _______am/pm to _______ am/pm
Thursday _____am/pm to_______am/pm
Application (1)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
Also Defendant requests release _____ hour(s) prior to employment until _____hour(s) after
employment for transportation.
If transportation by bus, defendant requests release _____hour(s) prior to employment until
_____hour(s) after employment.
If you request over 45 hours a week, explain why _________________________________
_________________________________________________________________________
5.
6.
Defendant will not be absent from his/her place of employment except for one meal with-in a
reasonable distance from the work site, nor be at any residence not approved as a work site.
List below people who will provide transportation:
a) ____________________________________________________________________
Name and Drivers Lic #
____________________________________________________________________
Address, City, State & Zip
____________________________________________________________________
Phone #’s, home, work & cell
b) ____________________________________________________________________
Name and Drivers Lic #
____________________________________________________________________
Address, City, State & Zip
____________________________________________________________________
Phone #’s, home, work & cell
c) ____________________________________________________________________
Name and Drivers Lic #
____________________________________________________________________
Address, City, State & Zip
____________________________________________________________________
Phone #’s, home, work & cell
7.
If providing your own transportation you must be listed above.
8.
Defendant’s supervisor at work has agreed to supervise this work release and agrees to notify the
The Corrections Facility of any change from the proposed rules.
9.
Do you currently owe child support? yes or no (circle one)
If yes, what’s the docket and page or CI #’s_______________________________________
10.
How many dependents do you have at home? _____ List name(s)
_________________________________________________________________________
Application (2)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
11.
Defendant understands that a condition of work release requires him/her to endorse all
paychecks while incarcerated to the Clerk of the District Court. Any violation of the Order or
law may result in disciplinary action, suspension and or revocation of work release privileges.
12.
Defendant understands his/her paycheck will be disbursed as the Court directs. In cases where the
defendant has been committed to a court supervised work release program because of a
contempt conviction for failure to pay permanent child support payments, the Clerk shall disburse
such funds in the following order of priority: DO NOT COMPLETE SECTION #13.
A.
Pursuant to Neb. Rev. Stat. 42-358.03 (reissue 1993), 90% of the earnings realized by the defendant,
less the cost of work release, shall be applied to payment of delinquent child support. (Defendant’s
earnings x .90 - Cost of Work Release = Amount to be applied toward payment of defendant’s
delinquent child support payments)
1. Support of the defendants dependents in Docket _______ Page_______ or CI #_______.
B.
Cost of Board
C.
Cost of Work Release
D.
Support of the defendant’s dependents residing with him/her in the amount of $_____________
per paycheck sent to:
__________________________________________________________________________
Name
__________________________________________________________________________
Address, City, State & Zip Code
E.
Costs, fines and restitutions ordered by the Court
F.
Defendant’s expense allowance of $___________________________ per paycheck
G.
Balance, if any, to defendant upon release.
13.
In all other cases, the Clerk shall disburse such funds in the following order of priority:
DO NOT COMPLETE SECTION #12
A.
Cost of Board
B.
Cost of Work Release
C.
Support of the defendants dependents in Docket _______ Page _______ or CI # ______________ in
the amount of $____________ per paycheck.
Application (3)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
D.
Support of the defendant’s dependents residing with him/her in the amount of $_____________
per paycheck sent to:
__________________________________________________________________________
Name
__________________________________________________________________________
Address, City, State & Zip Code
E.
Costs, fines and restitutions ordered by the Court
F.
Defendant’s expense allowance of $________________ per paycheck
G.
Balance, if any, to defendant upon release.
WHEREFORE, defendant prays the Court approve his/her Application for Work Release.
Dated this _______ day of ______________________________, 20___
________________________________________________________________________________
Defendant or Attorney’s Signature
________________________________________________________________________________
Defendant’s mailing address NOT jail or LCF
________________________________________________________________________________
City, State & Zip Code
________________________________________________________________________________
Phone Numbers - work #, home #, cell
This is to acknowledge that I have read paragraph #11 and understand that while incarcerated I must endorse all
checks over to the Clerk of the District Court.
________________________________________________________________________________
Defendants Signature
Application (4)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
COMMENTS OF DEPARTMENT OF CORRECTIONS
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
The Corrections Department has reviewed this Application and recommends:
approval
_______________
Date
or
disapproval.
_______________________________________
Corrections Department
American LegalNet, Inc.
www.FormsWorkflow.com
IN THE DISTRICT COURT OF LANCASTER COUNTY, NEBRASKA
STATE OF NEBRASKA,
__________________________________
Plaintiff,
vs.
__________________________________
Defendant
)
)
)
)
)
)
)
)
)
Docket _________ Page __________
or
CR/CI # _______________________
ORDER
1.
Commencing on the __________ day of ________________________, 20____, the defendant is
permitted to leave the Corrections Facility for employment at:
____________________________________________________________________________________
Employer
____________________________________________________________________________________
Address, City, State & Zip Code
____________________________________________________________________________________
Phone #’s - work, home & cell
During the following actual hours of employment, circle am or pm as it applies:
Monday ________am/pm to_____am/pm
Friday ________am/pm to _____ am/pm
Tuesday ________am/pm to_____am/pm
Saturday ______am/pm to _____ am/pm
Wednesday _____am/pm to_____am/pm
Sunday _______am/pm to _____ am/pm
Thursday _______am/pm to_____am/pm
Also, defendant is to be released for transportation ________hour(s) prior to employment and is to return to
confinement _______ hour(s) after completion of employment each day.
If transportation is by bus, defendant requests release _______ hour(s) prior to employment until ________
hour(s) after employment.
____________________________________________________________________________________
Supervisor(s) Name - Phone #’s - work, home & cell
Order (1)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
2. Should the employer not require the services of the defendant on any given day, he/she will notify the
Corrections Facility _________ hour(s) in advance. Also, should the defendants services not be needed for the
entire work period he/she will return to the Correctional Facility immediately.
3. This release is conditioned upon the defendant providing his/her own meals while absent from the Corrections
Facility during the times the meals are served therein, and also furnishing his/her own transportation to and from
work.
4. Defendant shall not be absent from his/her place of employment except for one meal within a reasonable
distance from the work site, nor be at any residence not approved as a work site.
5. Transportation for work release will be provided by:
a) ____________________________________________________________________
Name and Drivers Lic #
____________________________________________________________________
Address, City, State & Zip
____________________________________________________________________
Phone #’s, home, work & cell
b) ____________________________________________________________________
Name and Drivers Lic #
____________________________________________________________________
Address, City, State & Zip
____________________________________________________________________
Phone #’s, home, work & cell
c) ____________________________________________________________________
Name and Drivers Lic #
____________________________________________________________________
Address, City, State & Zip
____________________________________________________________________
Phone #’s, home, work & cell
If providing your own transportation you must be listed above.
6. Defendant understands that a condition of work release requires him/her to endorse all paychecks
for earnings while incarcerated to Clerk of the District Court.
7. The defendant’s employer shall mail the wages/salary earned by the defendant while incarcerated unless the
Order indicates Direct Deposit is authorized and prior arrangements made with Corrections.
Clerk of the District Court
Work Release Program
575 S. 10th St.
Lincoln, NE 68508
Order (2)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
8. This Order will remain in effect until the defendant is released, revocation of this Order, termination of
employment or further order of the court, whichever comes first. Any violation of the Order or the law may
result in disciplinary action, suspension and or revocation.
9. The Clerk shall mail a copy of this Order to the employer.
10. In cases where the defendant has been committed to a Court supervised work release program
because of a contempt conviction for failure to pay permanent child support payments, the Clerk shall
disburse such funds in the following order of priority: DO NOT COMPLETE SECTION “11".
A. Pursuant to Neb. Rev. Stat. 42-358.03 (reissue 1993), 90% of the earnings realized by the defendant, less
the cost of work release, shall be applied to payment of delinquent child support. (Defendant’s earnings x .90 Cost of Work Release = Amount to be applied toward payment of defendant’s delinquent child support
payments)
1. Support of the defendants dependents in Docket _______ Page_______ or CI #_______.
B. Cost of Board
C. Cost of Work Release
D. Support of the defendant’s dependents residing with him/her in the amount of $_____________
per paycheck sent to:
__________________________________________________________________________
Name
__________________________________________________________________________
Address, City, State & Zip Code
E. Costs, fines and restitutions ordered by the Court
F. Defendant’s expense allowance of $___________________________ per paycheck
G. Balance, if any, to defendant upon release.
11. In all other cases, the Clerk shall disburse such funds in the following order of priority:
DO NOT COMPLETE SECTION #10
A. Cost of Board
B. Cost of Work Release
Order (3)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
C. Support of the defendants dependents in Docket _______ Page _______ or CI # ______________ in the
amount of $____________ per paycheck.
D. Support of the defendant’s dependents residing with him/her in the amount of $_____________
per paycheck sent to:
__________________________________________________________________________
Name
__________________________________________________________________________
Address, City, State & Zip Code
E. Costs, fines and restitutions ordered by the Court
F. Defendant’s expense allowance of $________________ per paycheck
G. Balance, if any, to defendant upon release.
Below to be completed by District Court Judge/Referee only.
Dated this _______________ day of __________________________, 20____.
BY THE COURT:
_________________________________________________________
District Court Judge/Referee
Order (4)
January 2006
American LegalNet, Inc.
www.FormsWorkflow.com
