# REQUEST FOR WARRANT

DEFENDANT:___ DATE OF BIRTH 05-25-1979

HABITUAL OFFENDER: YES ___ NO ___ A/K/A ___

<table><tr><td>VICTIM RELATED / ACOUAINTED WITH DEFENDANT?</td><td>YES</td><td>XX</td><td>NO</td></tr></table>

05-368(2)

LEAD OFFICER: Det. Joe Recaery

AGENCY: PALM BEACH POLICE DEPARTMENT PHONE NUMBER:

CURRENT SHIFT HOURS: 8 am TO 5 pm DAYS OFF: ___

LEAVE / SHIFT CHANGE INFO: ___

WAS ARREST MADE FOR, OR IN CONJUNCTION WITH ANOTHER AGENCY. IF SO, WHAT AGENCY?:





SENTENCING RECOMMENDATIONS: CONTACT DETECTIVE

ADDITIONAL COMMENTS: ___





FILING DOCUMENTS ATTACHED:

P. C. AFFIDAVIT (2 COPIES)

WITNESS / EVIDENCE LIST Previously given TO ASA DELOHANEK



SWORN STATEMENT OF MATERIAL WITNESS(ES)



OFFENSE REPORT (2 COPIES)

WITNESS STATEMENTS (ALL)

FCIC/NCIC CRIMINAL HISTORY Previously Given to ASA BELOWWEN REQUEST FOR CONVICTION LETTERS



ACCIDENT REPORTS (ALL)



X PROPERTY RECEIPT PREVICIUSLY Given

VEHICLE TOW RECEIPT



OTHER ATTACHMENTS INCLUDE:







JR

INITIAL FOR COMPLETENESS:

7915

OFFICER

SUPERVISOR

DETECTIVE

RECEIVED

WAY 01 200c

STATE ATTORNEY'S OFFICE ON

INTAKE

BY:

EFTA00180596

# ARREST / NOTICE TO APPEAR

**Juvenile Referral Report**

| OBTS Number | ARREST / NOTICE TO APPEAR |
| :--- | :--- |
| Agency Name | Palm Beach Police Department |
| Agency Ration Number | N/A x A body |

## ADMINISTRATION

| Location of Arrest (including Name of Business) | Location of Offenses (Business Name, Address) |
| :--- | :--- |
| Date of Arrest | Time of Arrest | Booking Date | Booking Time | Jail Date | Jail Time | Location of Vehicle |

## DEPARTMENT

| Name (Last, First, Middle) | Alias (Name, DOB, Sec, #, Eat.) |
| :--- | :--- |
| Race | W/ White | Sex | Date of Birth | Height | Weight | Eye Color | Hair Color | Completion | Build |
| Social, Medical, Tobacco, Unique Physical Features (Location, Type, Description) | Marital Status | Religion | Vaccination of Aboriginal Reference Dog | Residence Type | Pounds Out of State | Address Source |
| Local Address (Street, Apt. Number) | (City) | (State) | Zip | Phone | | | |
| Permanent Address (Street, Apt. Number) | (City) | (State) | Zip | Phone | | | |
| Business Address (Name, Street) | (City) | (State) | Zip | Phone | | | |

## COURSE

| DL Number, State | Soc. Sec. Number | IPS Number | Plate of Birth (City, State) | Citizenship |
| :--- | :--- | :--- | :--- | :--- |
| Co-Defendant Name (Last, First, Middle) | Race | Sex | Date of Birth | 1. Amled | 2. Friendly | 3. Moderate | 4. Juvenile |
| Co-Defendant Name (Last, First, Middle) | Race | Sex | Date of Birth | 2. Amled | 3. Friendly | 4. Moderate | 5. Juvenile |
| Address (Street, Apt. Number) | (City) | (State) | Zip | | | |

## TOTAL

| TOTAL | Date | Time |
| :--- | :--- | :--- |
| The above address was provided by □ defendant and / or □ defendant's parents. The child and/or parent was sent to keep the Juvenile Court (D.C.) Office (phone 855-2506) informed of any change of address. | School Attended | Grade |
| Property Crime? | No | Reason | Value of Property |
| Drug Activity | Sick | B. Dementia | X. Depression | M. Manufacture/Product Distribute | C. Manufacture/Human | H. Madisonigan/O. Manhattan/O. Optimum/Danica | P. Paraphernalia/Symbology |
| Charge Description | Counts | Domestic Violence | Y. N | Warant/Capas Number | Bond |
| Drug Activity | Drug Type | Amount/Unit | Offense # | Warant/Capas Number | Bond |
| Charge Description | Counts | Domestic Violence | Y. N | Statute Violation Number | Bond |
| Drug Activity | Drug Type | Amount/Unit | Offense # | Warant/Capas Number | Bond |
| Charge Description | Counts | Domestic Violence | Y. N | Statute Violation Number | Bond |
| Drug Activity | Drug Type | Amount/Unit | Offense # | Warant/Capas Number | Bond |

## AGREEMENT TO APPEAR AT THE TIME AND PLACE DESIGNATED TO ANSWER THE OFFENSE CHARGED OR TO MY FINE SUBSCRIBED. I UNDERSTAND THAT SHOULD I WILLIFULLY FAIL TO APPEAR BEFORE THE Court IS REQUIRED BY THIS APPLE. TO APPEAR, I MAY BE INFRIED IN CONTENT OF Court AND A WARRANT FOR MY ARMEST SHALL BE ISSUED.

Signature of Defendant (or Juvenile and Parent) (Custodian)

| Location (Court, Room Number, Address) |
|------------------------------------|
| Court Date and Time | Month | Day | Year | Time | A.M. | P.M. |

## NOTICE

| NOTICE | Signature of Anesthetist Officer |
| :--- | :--- |
| Name of Anesthetist (Print) | ID. # |
| Make Deputy | ID. # |
| Transporting Officer | ID. # |
| Agency | Wireless here if subject signed with an "X" |

## NAME OF OTHER AGENCIES

| Agency Name | Name Verification (Printed by Anesthetist) |
| :--- | :--- |
| Name of Anesthetist (Print) | ID. # |
| Make Deputy | ID. # |
| Transporting Officer | ID. # |
| Agency | Wireless here if subject signed with an "X" |

<table><thead><tr><th>DISTRIBUTION:</th><th>WHITE — COURT COPY</th><th>GREEN — STATE ATTORNEY</th><th>YELLOW — AGENCY</th><th>PINK — JAIL</th><th>GOLD · DEFENDANT (N.T.A&#39;s ONLY)</th></tr></thead></table>