
DEPARTMENT OF CORRECTIONS AND REHABILITATION
ACP APPLICATION AND VOLUNTARY AGREEMENT
CDCR 2234 (07/12)
The Alternative Custody Program (ACP) is a voluntary program that promotes parenting, family reunification and the development of life skills
while addressing treatment needs. The ACP allows inmates to be housed in a personal residence, a transitional care facility or a residential drug
or treatment program instead of serving time in prison. I understand placement into the ACP is based upon meeting specific eligibility criteria
and the California Department of Corrections and Rehabilitation has the authority for final placement approval based on bed availability and
other factors. While participating in the ACP, I will be subject to applicable rules and regulations governing inmates pursuant to the California
Code of Regulations (CCR), Title 15, Division 3. I understand I may be removed from the ACP and returned to prison to serve the remainder of
my original sentence for any reason, with or without cause.
I. TO BE COMPLETED BY INMATE
I meet the criteria set forth in the CCR Title 15, section 3078.2 including the following: (Check all that apply)
I agree to apply for any county, state or federal medical coverage for which I may qualify.
I have private medical insurance.
I request to reside at the following location:
My private residence is located at:
(I understand my residence must have no aggressive animals, no weapons,
unobstructed access by law enforcement and will be verified by a Parole Agent.)
(Include street address, city, county and zip code)
The contact person at the above address is:
My relationship to the contact person is:
The contact person’s telephone number is:
Residential Drug or Treatment Program or Transitional Care Facility
I understand that my signature on this document indicates my willingness to voluntarily participate in the ACP.
II. FOR USE BY INSTITUTION COUNSELING STAFF
Does the participant have a qualifying disability requiring effective communication? Yes No
If yes, cite the source document and/or observation(s): ___________________________________________________________________
What type of accommodation/assistance was provided to achieve effective communication to the best of the inmate’s ability?
COUNTY OF LAST LEGAL RESIDENCE
CORRECTIONAL COUNSELOR NAME (PRINT)
CORRECTIONAL COUNSELOR SIGNATURE
III. FOR USE BY ACP PROGRAM MANAGER
IV. FOR USE BY PAROLE UNIT
RECEIVING AGENT ASSIGNED TO INVESTIGATE
AGENT’S RECOMMENDATION
Proposed residence meets criteria Yes No
PAROLE AGENT NAME (PRINT)
UNIT SUPERVISOR APPROVAL
Concur with agent’s recommendation
Yes No
UNIT SUPERVISOR NAME (PRINT)
UNIT SUPERVISOR SIGNATURE
UPON COMPLETION OF PRIVATE RESIDENCE VERIFICATION - RETURN THIS FORM TO THE SENDING INSTITUTION C&PR OFFICE
*EPRD means Earliest Possible Release Date Distribution: Original to c-file; copy to inmate