EFTA00109588

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# FEDERAL BUREAU OF JUSTICE

## ABOUT THE DEPARTMENT OF JUSTICE

### NAME: Last MONTGROVE
### FIRST: 2016F
### MIDDLE:

## AKAS:

**Race (Check)**
- **B** - A - I
- **M** - F
- Sex (Check)
  - Ethnic Origin (Check)
    - Hispanic or Other
  - D.O.B.: 1942-07-22
  - SSN:

## CHARGES:
**CHECK CATEGORY OF CHANGES(S):**
- FEIJONY
- MISDEMEANOR
- CIVIL CONTEMPLATION
- MATERIAL WITNESS OTHER

**WARRANTY:**
- Title: USC
- Warranty: USC
- Title: USC

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

## State of Birth
- Country of Birth: US
- Citizenship:

## Height
- Pt. In: Hair: Hair: Eyes: Eyes

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

## Arranged
- Sentenced
- Special Handling: Y or O

## Remand Official (Name)
Sign:
Print:

## Removal Official (Name)
Sign:
Print:

## FOR BOP USE ONLY

## Receiving Official (Name)
Sign:
Print:

## Sentry Load Data (Match Initial)
Name Search Completed by:

## Clearance/Separate Checked By:

## Clothing Bag #

### Agency/District
- Agency/District: Phone/24 Hour Number

### Release Official (Name)
Sign:
Print:

### Staff Init:
- Staff Init: RIGHT THOMPSONPRINT

### Deposit Cash Account:
- Deposit Cash Account: DETAINERS

### Clothing Bag #
This form replaces BP-8377(58) and BP-377(58) of JUL 91