EFTA00109764

# U.S. DEPARTMENT OF JUSTICE

APRIVING OFFICER WILL COMPLETE ALL REQUIRRED DATA ON THIS FORM PRIOR TO COMMITTING TO RECOMMENDATION.

Name: Last
CONTENT

First

Middle

PETITION

AKAa:

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

CHANGES CHECK CATEGORY OF CHARGES(S):
MISDEMEANOR
CIVIL CONTEMPLATION
MATERIAL WITNESS OTHER

NARRATIVE:
Title: USC: 951
NARRATIVE:
Title: USC: 951

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

State of Birth
Country of Birth
Citizenship
Current Address
Zip Code

Weight
Pt. In:
Weight
Hait
Eyes
Scars / Marks / Tattoos

Injuries / Medication

Emergency Contact:(Name, Address, Phone Number)

Arraigned
Y  N
Sentenced
Y  N
Special Handling: Y or N
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 Official (Name)
Sign
Print

Date / Time
Receiving Official (Name)
Sign
Print

Sentry Load Data (Hunt Initial)
Name Search Completed by:
Clearing/Separate Checked by:

UTILITY USE:
ARS Code
And AKA a
Cash Account
Deposit Cash
Container
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 (Imate); Copy-INS-Allen in Custody.

This form may be replicated via WP)