EFTA00109590





# U.S. DEPARTMENT OF JUSTICE

## ARRESTERING WILL COMPUTE PERSONAL REQUIRED DAYTON HAS FORM BRIDGE TO CORNWICH.

| Name: Last | First | Middle |
| :--- | :--- | :--- |
| AKAs: |

**RACE (Check)**
- B  W A  I
- M  W  I

**CHANGES CHECK CATEGORY OF CHARGES(S):**
- FELONY
- USC:
- NARRATIVE:
- NARRIVE VE:
- Title:

**CHANGES CHECK CATEGORY OF CHARGES(S):**
- MISDPEMANOR
- CIVIL CONTEMPT
- MATERIAL WITNESS OTHER

**DATE OF OFFENSE:** Date of Arrest: Place of Arrest:

**State of Birth**
- Country of Birth
- Citizenship

**Height In:**
- Weight
- Hair
- Eyes

**Scars / Marks / Tattoos**

**Injuries / Medication**

**Arraigned Y N**
- Sentenced Y N
- Remarks:

**IN**
- IN
- IN

**Remanding Official Sign**
- name
- Agency/District

**Print**
- OUT
- OUT

**Removing Official (Name) Sign**
- name
- Agency/District

**Print**

## FOR BOP USE ONLY

**Receiving Official (Name) Sign**
- Date / Time
- Receiving Official (Name) Sign
- Date / Time
- Print

**Sentry Load Data (Must Initial)**
- Name Search Completed by:
- Clearance/Separate Checked by:

**(OPTIONAL USE)**
- Staff Init.
- Add ARVs
- Create Cash Account
- Delete Fash
- Detailer
- Clothing Bag #

**RIGHT THUMBPRINT**

**Original-for ISM as Remanding-Removal receipt**
Copy-for Control as Removal Receipt (NCIC); Copy-For Removing Official; Copy-for Control as Remanding Receipt (Immediate); Copy-INS-Alien in Custody.

This form may be replicated via NP)

BP-5771.058 PRISONER REMAND CUFMU
TP-34 FEDERAL BUREAU OF PRISONS

Releasing Sign Print