EFTA00109581



646-836-6300 EXT 6390


CDFRM

# U.S. DEPARTMENT OF JUSTICE

ARRESTING OFFICER WILL CONFERENCE ALL REQUIRED DAYS ON THIS FORM PRIOR TO COMMITTING TO ACCOUNT:

| Name: Last | First | Middle |
| :--- | :--- | :--- |
| AXA:s: | | |

Race (Check) B W A I M F
Sex (Check) Ethnic Origin (Check) Hispanic or Other
D.O.B. SSN:
FBI: INS Other:

CHARGES CHECK CATEGORY OF CHARGES(S):
PELONY MISSEMGEANOR CIVIL CONTEMPT MATERIAL WITNESS OTHER
NARRATIVE: USC:
NARRATIVE: USC:
Title: USC:

Date of Offense: Date of Arrest: Place of Arrest:

State of Birth Country of Birth Citizenship Current Address Zip Code

Height Ft: Weight Hair Eyes Scars / Marks / Tattoos

Injuries / Medication Emergency Contact:(Name, Address, Phone Number)

Arraigned Y N Sequenced Y N Special Handling: Y or N

IN IN IN IN

Remanding Official (Name) Sign Agency/District Phone/24 Hour Number

Print

OUT OUT OUT

Removing Official (Name) Sign Agency/District Phone/24 Hour Number

Print

## FOR BOP USE ONLY

Receiving Official (Name) Date / Time Receiving Official (Name) Date / Time Print Print Print

Sentry Load Data (Just Initial) (OPTIONAL USE) Staff Init.
Name Search Completed by:
Clearance/Separate Checked by:
Clothing Bag RIGHT THUMBPRINT

Sentry Load Data (Just Initial) (OPTIONAL USE) Staff Init.
Name Search Completed by:
Clearance/Separate Checked by:
Clothing Bag RIGHT THUMBPRINT

Original-for ISM as Remanding-Removal receipt: Copy-for Control as Removal Receipt (NCIC); Copy-For Removal Official; Copy-for Control as Remanding Receipt (NCATE); Copy-NC-Alien in Custody.

(This form may be replicated via WP) BP-377(58) and