Arizona Furlough Request to ADCRR or the Board of Executive Clemency

Arizona Furlough Request to ADCRR or the Board of Executive Clemency

Before you use this: A.R.S. § 41-1604.11 applies only to a person whose felony offense was committed before January 1, 1994. For an offense committed later, this statute does not supply furlough authority. Send this written request to the decision-maker identified below, through the facility's applicable submission process.

To: ☐ Director, Arizona Department of Corrections, Rehabilitation & Reentry (temporary release under § 41-1604.11(B)) ☐ Arizona Board of Executive Clemency (work furlough under § 41-1604.11(C))

From: [INMATE FULL NAME], ADCRR No. [____________]

Facility and housing unit: [________________________________]

Date: [__/__/____]

Subject: Request for ☐ furlough / temporary release ☐ work furlough

I request the relief checked above under A.R.S. § 41-1604.11. I ask the appropriate decision-maker to review the facts, supporting materials, eligibility requirements, and proposed conditions below. I understand that this request does not itself authorize release.

1. Eligibility and requested purpose

Offense of conviction: [________________________________]

Date the felony offense was committed: [__/__/____]

Sentence and sentencing court: [________________________________]

Date admitted to ADCRR custody: [__/__/____]

Expected release date: [__/__/____]

Parole eligibility date, if relevant to work furlough: [__/__/____]

Director request under § 41-1604.11(B)

I request temporary release for the following statutory purpose (select one and state the facts):

☐ Compassionate leave: [person and circumstances; supporting records] [________________________________]

☐ Medical treatment unavailable at my prison or institution: [treatment, provider, and why unavailable there] [________________________________]

☐ Preparation for return to the community within 90 days of my release date: [release date and plan] [________________________________]

☐ Disaster aid, including local mutual aid or a state emergency: [assignment and need] [________________________________]

Board request for work furlough under § 41-1604.11(C)

☐ I request work furlough. I have served at least six months of my court-imposed sentence; I am within twelve months of my parole eligibility date; and I have not been convicted of a sexual offense. The Board must make its own statutory findings and approve release in its discretion.

Sentence time served: [________________________________]

Proposed employer, duties, schedule, and location: [________________________________]

Restitution plan, if applicable: [________________________________]

Facts supporting my ability to remain at liberty without violating the law and the state's interest in release: [________________________________]

2. Facts and supporting materials

The circumstances supporting this request are: [________________________________]

[________________________________]

I attach the following records (identify each attachment and avoid unnecessary sensitive details):

☐ Medical or compassionate-leave documentation: [________________________________]

☐ Release-date or reentry plan: [________________________________]

☐ Employment offer and schedule: [________________________________]

☐ Facility classification or disciplinary record: [________________________________]

☐ Other: [________________________________]

3. Proposed release plan

Dates and times requested: from [__/__/____] at [____] to [__/__/____] at [____]

Destination and address: [________________________________]

Transportation and responsible contact: [________________________________]

Telephone number for contact during release: [________________________________]

Supervision, reporting, and return plan: [________________________________]

I will follow the conditions imposed by the Director or Board, as applicable. I understand that the Director may require reimbursement of state expenses for temporary release preparatory to community return or for compassionate leave under § 41-1604.11(B). If the Board grants work furlough, I will comply with its conditions, including employment and restitution requirements under § 41-1604.11(F).

4. Request

I request that the Director or Board, as applicable, consider this request and issue a written decision through the appropriate institutional process. If the Board considers work furlough, I request that it provide any notice and hearing required by § 41-1604.11(E).

Applicant signature: [________________________________] Date: [__/__/____]

Counsel or authorized representative, if any: [________________________________]

Representative contact information: [________________________________]

Facility receipt / routing (if used): [________________________________]

Source

Arizona Legislature, A.R.S. § 41-1604.11, accessed October 12, 2026. Subsection (B) assigns the listed temporary-release decisions to the Director; subsection (C) assigns work furlough to the Board; subsection (E) gives the sentencing judge a notice and opportunity to be heard on request, rather than power to grant furlough; subsection (M) limits the entire section to felony offenses committed before January 1, 1994.