EFTA00109756

# U.S. DEPARTMENT OF JUSTICE

## REMARKING OFFICER: WILL CORRECT ALL REQUIRED DATE OF THIS FORM BEFORE GO TO COMMITTING AGGREGATE MCC/MCMS.

**Name:** Las **First:** Middle

**AkAs:**

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

**CHARGES CHECK CATEGORY OF CHANGES (S):**
- OTHER
- NARRATIVE:
  - Title: USC.
  - Title: USC:

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

| State of Birth | Country of Birth | Citizenship | Current Address | Zip Code |
| :--- | :--- | :--- | :--- | :--- |
| Height Pt. In: | Weight | Hair | Eyes | Sears / Marks / Tattoos |

**Injuries / Medication**

| Injuries / Medication | Agency/District | Phone/24 Hour Number |
| :--- | :--- | :--- |
| Arraigned Y N | Sentenced Y N | Special Handling: Y O Remarks: |

**IN** **IN** **IN** **IN**

Remanding Official (Name) Sign Print

Agency/District Phone/24 Hour Number

**OUT** **OUT** **OUT**

Removing Official (Name) Sign Print

Agency/District Phone/24 Hour Number

## FOR BOP USE ONLY

### Receiving Office Sign Print

- Date / Time: Release Official (Name) Sign Print
- Print

**Entry Load Date:** (Not Initial)
Name Search Completed by:
Clearance/Separate Checked by:

OPTIONAL USP Add ARXS Delete Cash Account Delete Cash Account Detainees Clothing Bag #

**Staff Init.:**

RIGHT THUMPRINT

### Original-for ISM as Remanding-Removal receipt: Copy-for Control as Remanding Receipt (NCCI); Copy-For Removing Official; Copy-for Control as Remanding Receipt (Immediate); Copy-INS-Alters an Autopsy. This form may be replicated via WF)

BP-5377(58) and BP-3777(58) of DUL 91