(only use when IOMS is not available)
Date
Sponsor Name
Prison
Street Address
Street Address
Suburb
Suburb
Town / City Postcode
Town / City Postcode
Dear Sponsor Name
1982
M.04.06.Form.07 Temporary  Release  Letter  to  Sponsor
Act
Approval has been given for Prisoner name to have a temporary release with you as a
sponsor.
If this is his/her first temporary release with you during his/her present sentence, you will
be required to read the list of conditions set out below, and if you are satisfied these
Information
conditions can be abided by, please sign this confirmation form and return it to me as
soon as possible.
If he/she has been on temporary release with you before at the same address during
Official
his/her present sentence, please sign this confirmation form and return it to me as soon
as possible.
the
The general conditions of his/her temporary release are:
1. Prisoner name is to be picked up by you for temporary release for the following
period,  D a t e   T i m e  and must be returned by you at no later than D a t e   T i m e .
under
You must bring suitable identification prior to collecting Prisoner name and your
copy of the  temporary release papers.
2. He/She is to be on good behaviour and commit no offence against the law.
3. That he/she totally abstains from consumption of alcohol and any drugs not
Released
prescribed by a registered Medical Practitioner.
4. That he/she remains in the presence of his sponsor for the entire period of his
temporary release and only  resides at your address.
5. That he/she does not associate with drug users or suppliers.
6. That he/she does not enter any TAB or licensed premises.
7. The area of the temporary release is restricted to: (Residential or other area
restriction)
8. He/She is not to drive any motor vehicle whatsoever.
9. As Per Temporary Release Licence
POM-M.04.06.Form.07 Temporary Release Letter to Sponsor
Last updated: 17 Sep 2017
Page 1 of 2

(only use when IOMS is not available)
I Sponsor Name, have read and understand all conditions that are to be adhered to
pertaining to Prisoner name temporary release.

Signed
(Sponsor)
Date / /

1982
Act
Information
Official
the
under
Released

POM-M.04.06.Form.07 Temporary Release Letter to Sponsor
Last updated: 17 Sep 2017
Page 2 of 2

M.04.06.Form.05 Licence for temporary release from custody
(Under section 62 of the Corrections Act 2004)

Prison

Phone

Date
To:


(Full name of Prisoner)
You are being released, temporarily, from this prison for the purpose of


THE CONDITIONS OF THE TEMPORARY RELEASE ARE THAT YOU:
1.
Go to

(specified area)

and do only what your temporary release allows you to do, as stated above.
1982
2.
Must behave well and commit no offence against the law.
Act
3.
Must return to this Prison no later than


on the

day of


  (time)

(date e.g. 1st)

(Month)
  (Year)

or earlier if so directed by the General Manager Custodial or the Chief Executive (or their delegates).
4.
Must produce this Licence if a police officer, probation officer or prison officer asks you to.
Information
5.
Must not possess, and / or consume, and / or use alcohol and / or drugs (excluding prescription medicines),
or enter any licensed premises.
6.
Must not drive any motor vehicle, whether your own, or otherwise, other than in an emergency situation. If
you are being released to work, you may seek approval to drive.
Official
Additional Conditions


the
Acknowledgements

NOTE TO PRISONER
under
Read this carefully, before you sign and date the form in the space below.
  I have received a copy of this form allowing my temporary release.
  I have had the provisions of relevant sections of the [Corrections Act 2004] on the back of this form pointed
out to me.
  I agree to carry out the conditions of temporary release as set out on this form.
  I consent to the disclosure to my proposed sponsor, of personal information about my offending.
  I understand that if I do breach these conditions I make myself liable to arrest for escape
Released
  I acknowledge that the Police will be advised of the date of my temporary release, the prison from which I am
released, and the conditions of my release (whether imposed on release or subsequently), including the area
I am released to.
Prisoner
Date

Sponsor agreement to not disclose any personal information about the above named prisoner supplied with the
consent of that prisoner about his/her offending.
Sponsor acknowledgement (if applicable)
Date

General Manager Custodial
Date


3 Copies
1. Prisoner copy
2. File copy
3. Control Centre
M.04.06.Form.05 Licence for temporary release from custody
Page 1 of 2

CORRECTIONS ACT 2004

62(2)  The chief executive may give authority for the temporary release
from custody or temporary removal from prison of a prisoner….

63(1)  Any temporary release from custody under section 62 is for a period
fixed by the chief executive and may be subject to conditions
imposed by the chief executive.

63(2)  The chief executive or the prison manager may, at any time, direct
the return to a prison of any person temporarily released from
custody under section 62.

1982
63(3)  Every person temporarily released from custody under section 62 is
deemed to be unlawful y at large if he or she -
Act
a.
is at large after the expiry of the period for which he or she was
so released; or
b.
is at large after the giving of a direction for his or her return to a
prison under subsection 63(2); or
c.
breaches any condition imposed under section 63(1) requiring
the person to stay at any place or within any geographical area,
Information
to stay with a particular person or group, or to attend a particular
programme or course.

63(4)  If any person released under this section is at large without
Official
reasonable excuse (the proof of which excuse lies on him or her)
after the expiry of the period for when he or she was released, after
the
the giving of a direction under subsection 63(2), or after the person
breaches any condition referred to in subsection 63(3)(c), he or she
is deemed to have escaped from lawful custody and is liable
accordingly.  under

Released
M.04.06.Form.05 Licence for temporary release from custody
Page 2 of 2

M.04.06.Form.01 Notification to the Police of a temporary
release from prison custody

Surname

First name

Date of birth
Current age
Classification

PRN
Prison

Unit

Cell


Instructions:  Please complete this form and send to the Police at least five (5) working days prior to the
date of temporary release or immediately after the appropriate authorities approval if less time is available.
☐ Prisoner is subject to CSO Register
Other relevant information

1982

Temporary release starts
(Date)

(time)
Act
Conditions of temporary release

Sponsor (s)

Form completed by

Position

Information

Insert photo in the box
Official

the
under

Released

POM-M.04.06.Form.01 Notification to the Police of a temporary release from prison custody
Last updated: 12 Oct 2016
Page 1 of 1

M.04.05.Form.02 Temporary removal application details

Date:
Prisoner’s Details
Site:                          Prison:
Prisoner’s surname:
First names:

PRN:

Sentence:
Offences:

1982

SCD:                           PED:                            SED/SRD:
Act

Security Classification:
  Maximum
  High
  Low Medium
  Low
  Minimum
  Unclassified

Proposed Temporary Removal Details:

Purpose of the proposed Escorted Outing:
Information

Location of Proposed Temporary Removal:
Official

the

Date of Proposed Temporary Removal: on/from………./………./……….  To
………../………./……….
Duration:
under
Transport arrangements:
Time of Departure:                                                        Time of Return:
Number of Officers:
Costs: How will the costs associated with the Temporary Removal be met?

Released
Prisoner’s signature:
Date:      /        /

Escort arrangements:
Transport Arrangements:

Name of Escorting Officer (Must have Level Three NZQA Unit Standard Escort Prisoners):


POM-M.04.05.Form.02 Temporary removal application details
Last updated: 01 Jun 2018
Version 04
Page 1 of 2

Behaviour within Prison:
(Include details of the prisoner’s sentence management, other activities, details of any
previous temporary removals and responses to those).

Is the temporary removal recommended by the New Zealand Parole Board: Yes
     No

N/A

Other Relevant Information:

1982

Act
Prepared by
Date

The Manager with the delegated authority to approve the application is to complete this
section.

Information
The temporary removal is:  Approved / Not Approved

Date:

If the application is not approved give reasons:
Official

the
If approved ensure the conditions are stated on M.04.01.Form.01 Instructions for
Escorts.
under
Released

POM-M.04.05.Form.02 Temporary removal application details
Last updated: 01 Jun 2018
Version 04
Page 2 of 2

  Requested Date and time:

Requested by:

Instructions for Escorts
Prisoner’s Details (ensure Offender Details Report is attached)
Surname:

First Names:
Address:
Occupation:
Gender:
PRN:
Age:
Date of Birth:
Location From:
Location To:


Security Classification:
  Max.
  High
  Low Medium
  Low
  Min.
  Unclassified
1982
Status:
  Sentenced
Remand:
  Accused
Convicted
Reason in Custody:
Act
Arrest Date:               Bail Date:             Arrest Date:            Bail Date:
Next Court Date:             Arrest Date:               Bail Date:             Arrest Date:            Bail Date:

Corrections must attach a copy of the printed IOMS Offender Details Report and a copy of
M.04.01.Form.06 Prisoner escort safety and security information.  Police will provide their risk
evaluation information and attach all Warrants to this escort handover form.  The information
Information
contained in either the Police or Corrections evaluations/assessments is to be considered and
recommended mitigation taken into consideration when determining/setting escort conditions.

Risks/Alerts
Identified risk Comments
Change
N/A
Official
Suicidal:



the
Assaults Law



Enforcement Officer:
Drugs:



under
Gang Affiliations:



Health



Escapes Custody



Released
Weapons




Special Instructions, Risk Mitigations and Medication:


POM-M.04.01.Form.01 Instructions for Escorts
Last updated: 22 Jan 2019
Version 04
Page 1 of 3

Handover of Prisoner
Receipt of prisoners and verbal instructions. Signature required for each hand over including the Final.

1
2
3
4
Name:




Signature:

Date:




TAG/Rank/Position:




Prison/Agency:





Incident / Issues during Escort
1982

(select one)
Describe  Act
Was the prisoner involved in any incidents
Yes  /
No

during the escort?
Was the prisoner involved in any incidents
Yes  /
No

while in the cells?
Was the prisoner involved in any incidents
Yes  /
No

during court?
Information
Additional paperwork attached
Yes  /
No

When the escort has finished, file this form in section G of the prisoner’s file.
Incident Details
Official

the
under
Property:
Number of packages
Description of Property
Total Cash: $
Released
Item #



Signature of Detainee:

Date:

POM-M.04.01.Form.01 Instructions for Escorts
Last updated: 22 Jan 2019
Version 04
Page 2 of 3

Handover of Property
Receipt of prisoner’s property and verbal instructions. Signature required for each hand over including the Final.

1
2
3
4
Name:




Signature:

Date:




TAG/Rank/Position:




Prison/Agency:





Escort Details
Date of Escort:

Purpose:
  Court
  NZPB
No. of Escorting staff:
1982
Mode of Transport:
  Car
Van
Bus
Plane      Other:
Destination:
Act
Route:
Authorised Stops:

Standard Instructions
Maintain strict security at all times.
Prisoners to be under direct supervision at all time.
Information
Make no unauthorised stops – travel directly to and from the destination.
Ensure that you carry communications equipment – you must contact the prison in case of emergency.
No unauthorized phone calls or visitors during the escort.
All documents related to the prisoner are held in a covered folder or satchel within the possession or
Official
control of staff.

the
Restraint Instructions


Verbal Authorisation (MCS or Del
under  egated person)
I
contacted
who gave verbal approval for this escort.
Date Contacted:
Time Contacted:

TAG/Rank/Position:
Date:
Released

Escort OIC (Must have Level Three NZQA Unit Standard Escort Prisoners or equivalent)
Prior to any escort departing a secure point, the officer in charge of the escort (OIC) must check that the
application of the handcuffs to the prisoner has been performed correctly, with the appropriate inserts
where required.
The OIC must check and confirm that the handcuffs are securely fitted prior to any escort departing.
Receipt of prisoners and verbal escort briefings.
Name:

Signature:

TAG/Rank/Position:
Date:

POM-M.04.01.Form.01 Instructions for Escorts
Last updated: 22 Jan 2019
Version 04
Page 3 of 3

1982
Act
Information
Official
the
under
Released

GPS Monitoring Sponsor Agreement
For use with Guided Release/Temporary Release enquiries

1.  Sponsor Understanding

I am over 16 years old and I have applied to be the approved sponsor for a prisoner
applying for a Guided Release/Temporary release from Prison. This release may include the
prisoner spending  time at my address. As such, I understand  an assessment  of my address
for the suitability of electronic monitoring must be carried out.

I understand  that a condition of this release  may include that the prisoner be monitored by
GPS.

1982
The Probation Officer must ensure I am aware of the nature of the prisoner’s past and
current offending to enable me to make an informed decision about whether I consent to the
prisoner undertaking a guided release/temporary release with electronic
Act monitoring with me
as the approved sponsor.  I understand I must not use this information for any other purpose.

The probation  officer wil ;
•  Provide a report to the Prison on:
•  The suitability of the address
•  The safety and welfare of the occupants of the address where the offender wil  be
Information
subject to monitoring.
•  Col ect the details of al  persons, including children, who reside either permanently or
part-time at, or regularly visit, the address, and
•  If necessary for the assessment, send information to and receive information from the
Official
Police, Child Youth and Family and other agencies as appropriate.

the
I can withdraw my consent at any time to have the prisoner at the address  while subject to
the guided  release/temporary release and electronic monitoring.


under
2. Obligations of relevant occupants

If I give consent to have the prisoner at the address  while subject to GPS monitoring,
electronic monitoring equipment may be instal ed  at the address  and would be attached to
the address’  power supply for the duration of the leave. I am aware the offender may be
Released
required to charge the battery, as explained by the Probation Officer.

Allowing the probation officer or authorised person entry to the address
I understand  that by providing consent for the prisoner to be with me and at my address
during the Guided release/temporary leave that I must al ow staff from the Department of
Corrections (Prison and/or Probation), any authorised  person (such as the monitoring
company) or Police entry to the residence at any time requested. This is for the purpose of
maintaining the monitoring equipment or the offender’s compliance with the monitoring.

GPS Monitoring Sponsor Agreement – Temporary/Guided Release
Last updated 14 Sept 2016

No interference with monitoring equipment
If I am found to have tampered with the equipment in any way I understand that this is likely
to jeopardise  my ability to continue as an approved sponsor  for temporary releases.

3.   Occupant criminal checks
As part of the assessment of address suitability,  the Department of Corrections wil  check for
any criminal convictions and active charges I may have. The Department of Corrections wil
conduct the checks via internal records and the Ministry of Justice. I am aware that the
Criminal Records (Clean Slate) Act 2004 does not apply in these circumstances so the
Department of Corrections wil  have access to my ful  criminal conviction history.

4.  Sponsor acknowledgement, agreement, and consent
The probation  officer has explained the requirements of my role as a sponsor while the
prisoner is subject to temporary leave and GPS monitoring.

I consent to the offender being at my address with me as the approved sponsor:

1982

_____________________
_____________
_____________________

Name of Sponsor
Date
Signature

Act
I consent to CP checking my criminal history*
YES / NO

Information
5.  Other Occupants (Over 16 years):
The probation  officer has explained the requirements of a temporary leave and GPS
monitoring and my obligations as an occupant.
I consent to having the offender at the address while subject to GPS monitoring.
Official

the
_____________________
_____________
_____________________

Name of Occupant
Date
Signature

I consent to CP checking my criminal history*
YES / NO

under

_____________________
_____________
_____________________

Name of Occupant
Date
Signature

I consent to CP checking my criminal history*
YES / NO

Released

_____________________
_____________
_____________________

Name of Occupant
Date
Signature

I consent to CP checking my criminal history*
YES / NO

GPS Monitoring Sponsor Agreement – Temporary/Guided Release
Last updated 14 Sept 2016

TO:
Prisons Service (PS)

Community Probation (CP):
Office /

Site:
The prisoner identified below has applied for a Guided Release activity/Temporary Release.  Could you
please ensure the following details are canvassed, and the completed form returned.

Due Date: _____________________(10 working days)

This is the application for temporary release from custody during this sentence.
I wish to emphasise that the Probation Officer should not give the sponsor any commitment regarding the
1982
possible outcome of the prisoner’s temporary release application.



  Act
Principal Case Manager
  Prison

Date
(signature)

(1)  PRISONER
Name:

PRN:
DOB:
Information
Sentence:

Commencement Date

(SCD):

Index
Official
Offence(s)
:
the
RoCRoI:    ________________________________
HRX?
Yes
No
Next NZPB Hearing: ________________________________

Proposed Activity:

under
Duration of Leave Requested:
(This must be specific or the request will not be progressed)
Time and Date of Requested Leave:

Initial Response of Sponsor:

Released

(2)  SPONSOR
Name:

Photo ID copied:
Yes
No
Address:

Contact Telephone

Mobile and/or Email (if
Number:
applicable)
2.1     Has the sponsor participated in Temporary Leaves for this offender previously:
Yes
No
          If yes, any known issues or concerns:

Sponsorship Assessment form – Temporary/Guided Release
Last updated 14 Sept 2016

2.2     Criminal History Check Completed:
Yes
No
          Outcome:

2.3  How long has the sponsor known the prisoner?

2.4  What is the sponsor's relationship to the prisoner?


2.5  Is there currently a protection or restraining order in force against the prisoner, in respect of either
the sponsor or any children of the sponsor?
Yes
No
          Confirmed with Police:
Yes
No
Details:

1982
2.6  Any other relevant information about the sponsor?
Yes
No

Act

2.7  Is the sponsor willing to have the prisoner on temporary release for the date and time sought or is a
different date requested?
YES /
NO (state requested date and time)

2.8  Is the sponsor able to supervise the prisoner at all times?
Yes
No
Information
          If not, what arrangements are anticipated for the prisoner’s supervision during the period(s) the
sponsor is unavailable?


Official
2.09   Has the sponsor been made aware of the prisoner’s offence for which the prisoner is currently
imprisoned?
the

Yes
No

2.10   Does the sponsor have a good understanding of the prisoner’s high risk situations and identified
risk factors?
under

Yes
No
   Details:

2.11  Has the sponsor read and signed the Sponsor General Agreement Form?
Yes
No

Released

(3)  ACCOMMODATION (TO BE VISITED AND ENTERED IF PROPOSED LEAVE INVOLVES A
HOME VISIT)
3.1  What is the accommodation?
HOUSE
FLAT
OTHER (state)

3.2  Is the accommodation the sponsor's established home?
Yes
No

Sponsorship Assessment form – Temporary/Guided Release
Last updated 14 Sept 2016

3.3  Are others sharing the accommodation?
Yes
No
          If yes, please provide details.


3.4  Are there concerns about any of the persons (including children and young persons) residing at the
proposed accommodation?
Yes
No

(4)  GPS MONITORING (TO BE COMPLETED IF PROPOSED LEAVE INVOLVES A HOME VISIT)
4.1  Has the Sponsor signed the GPS sponsor agreement?
Yes
No

4.2  Has an on site feasibility check been completed?
Yes
No
          (This is a requirement to ensure GPS data can be transmitted from the tracker while the prisoner is at the
address)
1982
           Outcome:

Act
4.3  Do Community Probation suggest specific inclusion/exclusion zones?
Yes
No
(Please detail these and the rationale for the zones)

(5)  VICTIM RELATED INFORMATION
5.1     VNR alert?
Yes
No
Information
          If yes, outcome of VNR check:

5.2  Are there any victim related issues with the proposal?
Yes
No
          If yes, detail concerns:
Official

(6) PUBLIC SAFETY
the
6.1    Could the release of the prisoner on Guided Release/temporary release create any adverse local
reaction,       including the safety of the public and any person or any group of persons?
Yes
No
         If yes, detail information:
under

6.2  Does the offender have any non-associations or protection orders that will need to be considered?

Yes
No
          If yes, detail who and why:

Released
         (Consideration should be given to  an additional condition of the temporary release relating to non-
associations)

6.3  Has a request for information been sent to Police in regards to the proposal and sponsor?
Yes
No
If yes, please detail response. If no, please explain why.

Sponsorship Assessment form – Temporary/Guided Release
Last updated 14 Sept 2016

6.4     Has a request for information been sent to CYF in regards to the proposal and sponsor?
Yes

No
If yes, please detail response. If no, please explain why.

(7)  TRANSPORT AND OTHER CONSIDERATIONS
7.1  Is the sponsor able and willing to transport the prisoner to and from the prison?
Yes
No

If no, what other provisions are planned for the prisoner’s transportation?


7.2    If the sponsor is planning to drive the prisoner, do they hold a valid NZ Drivers Licence?

Full
Restricted
Learner
No
         D/L Number:
1982
         Expiry Date:

Act
7.3    If the sponsor is planning to drive the prisoner, does the vehicle have current registration and WOF?

Yes
No
         Vehicle Details: Model/Make/Colour/Licence Plate
7.4  Are there any other matters that you are aware of that should be taken into account?
Yes
No
          If yes, please detail.
Information

7.5    Are there any other restrictive conditions of Temporary Release that should be considered?
Yes
No
         If yes, please detail what and why.
Official

the




Report prepared

Name

Position

Date
by

under

Service Manager Check Completed:

Yes  ______________________
             SM Name

Released

Attachments     Please scan and attach to email with completed Sponsor Assessment Form
Photo ID of sponsor
Sponsor Criminal and Traffic History
Sponsor General Agreement Form
Sponsor GPS Agreement Form (if applicable)
Other (Please Specify)


Sponsorship Assessment form – Temporary/Guided Release
Last updated 14 Sept 2016

Document Outline