REQUEST FOR WARRANT¶
DEFENDANT:___ DATE OF BIRTH 05-25-1979¶
HABITUAL OFFENDER: YES ___ NO ___ A/K/A ___¶
| VICTIM RELATED / ACOUAINTED WITH DEFENDANT? | YES | XX | NO |
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 |
DEPARTMENT¶
| Name (Last, First, Middle) | Alias (Name, DOB, Sec, #, Eat.) |
|---|---|
| Race | W/ White |
| Social, Medical, Tobacco, Unique Physical Features (Location, Type, Description) | Marital Status |
| Local Address (Street, Apt. Number) | (City) |
| Permanent Address (Street, Apt. Number) | (City) |
| Business Address (Name, Street) | (City) |
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 |
| Co-Defendant Name (Last, First, Middle) | Race | Sex | Date of Birth | 2. Amled |
| 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 |
| Drug Activity | Sick | B. Dementia |
| Charge Description | Counts | Domestic Violence |
| Drug Activity | Drug Type | Amount/Unit |
| Charge Description | Counts | Domestic Violence |
| Drug Activity | Drug Type | Amount/Unit |
| Charge Description | Counts | Domestic Violence |
| Drug Activity | Drug Type | Amount/Unit |
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 |
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” |
| DISTRIBUTION: | WHITE — COURT COPY | GREEN — STATE ATTORNEY | YELLOW — AGENCY | PINK — JAIL | GOLD · DEFENDANT (N.T.A's ONLY) |
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