Wufoo

Name * First Last
89) For what length of time were you incarcerated?
90) Were you incarcerated at more than one facility?
Yes No
a) If yes, provide list of facilities and duration of stay at each facility.
91) What were the conditions of your cell?
92) Were you fed sufficiently/regularly?
93) Were you denied commissary, visitation, phone, shower, or any other privileges?
94) Were you physically/mentally abused during incarceration?
Yes No
a) If yes, describe methods of abuse, names of individuals who committed the abuse.
b) Was the physically/mentally abuse a regular occurrence? (Yes/No) How often?
Yes No
If yes, how often?
95) Did you suffer any physical injuries as a result of physical abuse?
Yes No
a) If yes, describe injuries, names of individuals who inflicted the injuries.
b) Were you treated for these injuries? (How? Was it sufficient? Is the injury permanent?)
96) Were you subjected to solitary confinement?
Yes No
a) If yes, describe the number of days, reasons, conditions, etc.)
97) Were you suffering from any diagnosed physical/mental condition prior to incarceration?
Yes No
a) If yes, describe the condition(s). (Upload doctor reports, required medications, etc.)
(Upload doctor reports, required medications, etc.)

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b) Were you denied treatment/medications for the condition(s)?
Yes No
c) Did these conditions escalate during incarceration?
Yes No
98) Were you subjected to “Diesel Therapy” when moved to a different facility?
Yes No
a) Describe the conditions, length of time, treatment during these events.
99) Was any discovery/exculpatory evidence you gathered for your defense confiscated/lost by prison officials during your incarceration?
Yes No
a) Describe documents confiscated.
100) Did you suffer the loss of any earned benefits (VA, retirement, etc.) during your incarceration?
Yes No
a) Describe lost benefits, reasons given. (Upload corresponding documents.)
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101) Did the government confiscate funds donated to a Give-Send-Go or any other crowd-funding account established to help cover your legal expenses or to help your family meet expenses?
Yes No
a) Provide documentation

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