Blank Bureau of Prisons inmate intake and removal form

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¶