Dd Form 2791 - Notice Of Release/acknowledgement Of Convicted Sex Offender Registration Requirements Page 2

ADVERTISEMENT

NOTICE OF RELEASE/ACKNOWLEDGEMENT OF CONVICTED SEX OFFENDER REGISTRATION REQUIREMENTS
1. TO
STATE LAW ENFORCEMENT
LOCAL LAW ENFORCEMENT
STATE SEX OFFENDER REGISTRATION OFFICIAL
a. ADDRESS (Include ZIP Code)
b. DATE (YYYYMMDD)
Pursuant to 10 U.S.C. 951 (Note) and DODI 1325.7, paragraph 6.18.5, the Department of Defense is notifying your office of the release of
an offender who, based on available information, was convicted of a sex offense or a crime against a victim who was a minor. The offender is
subject to sex offender registration under Federal law. For additional information, please contact the point of contact with facility of release
who is identified below.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 951 (Note); DODI 1325.7, paragraph 6.18.5; and E.O. 9397.
PRINCIPAL PURPOSE(S): To notify an offender of the requirement to register upon release from confinement or military service with the state
authorities as a sex offender, to record the offender's acknowledgement of receiving notice of and information pertaining to the requirement,
and to obtain an offender's expected place of residence following release.
ROUTINE USE(S): To State and local law enforcement authorities for purposes of notification that a sex offender will be residing in a local
community and to State or local officials for purposes of registering the individual as a sex offender.
DISCLOSURE: Voluntary; however, failure to provide an expected place of residency may result in denial of your request for parole or delay
your release from confinement or military service.
2. NAME OF OFFENDER
3. DATE OF BIRTH
4. SOCIAL SECURITY NUMBER
(Last, First, Middle Initial)
(YYYYMMDD)
5. CURRENT AND PRIOR CRIMINAL HISTORY OF SEXUAL OFFENSE(S)
a.
b.
c.
SPECIFIC OFFENSE TITLE AND DESCRIPTION
DATE OF CONVICTION
PLACE OF CONVICTION
(5 words or more)
(YYYYMMDD)
6. FINAL RELEASE DATE
7. RELEASE CONDITIONS OR RESTRICTIONS
(YYYYMMDD)
8. OFFENDER'S ACKNOWLEDGEMENT OF SEX OFFENDER REGISTRATION REQUIREMENTS
I,
,
,
,
, was convicted and sentenced for
(Full Name - Last, First, Middle)
(Rank)
(Service)
(Social Security Number)
the commission of
a sexual offense
sexual offenses
an offense involving a
year old minor.
(YYYYMMDD).
I have been informed that I will be released from confinement or military service on or about:
I certify that upon release from confinement or military service I will reside at the following address:
(Initial)
(Street, Apartment Number, City, State and ZIP Code)
I hereby acknowledge that I was informed that upon my release from confinement or military service, I am subject to registration require-
ments as a sex offender in any State or U.S. territory in which I will reside, be employed, carry on a vocation, or be a student. I was further
informed that the chief local law enforcement officer of the jurisdiction in which I will reside upon release from confinement or military service
is being provided written notice of the date of my release from confinement or military service, the offense(s) of which I was convicted, and
that I am subject to a registration requirement as a sex offender. This notice will also be submitted to state law enforcement and sex offender
officials. I understand that I must contact the office that follows, to ensure that sex offender registration requirements are met:
(Initial)
(Organization, Address (Include ZIP Code), and Telephone Number)
I acknowledge that I was informed that every change in my address must be reported in the manner provided by State law. I also
acknowledge being informed that if I move to another state, I must report the change of address to the responsible agency in the state I am
leaving, and comply with the registration requirements in the new state of residence. I understand that the failure to register may constitute
grounds to revoke parole. Finally, I understand that if I fail to register and/or change or update such registration information as required under
a State sex offender registration program, I may be subject to criminal prosecution.
Signed on this
day of
,
.
WITNESS:
(Signed Name)
OFFENDER:
(Signed Name)
(Printed Name)
(Printed Name)
9. CONFINEMENT FACILITY OR COMMAND RELEASING OFFENDER
a. NAME OF FACILITY OR COMMAND
b. ADDRESS (Include ZIP Code)
10. CONFINEMENT FACILITY OR COMMAND POINT OF CONTACT
a. NAME (Last, First, Middle Initial)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE NUMBER
(Include Area Code)
11. CONFINEMENT FACILITY COMMANDER OR COMMANDER RELEASING OFFENDER
a. TYPED NAME (Last, First, Middle Initial)
c. DATE SIGNED (YYYYMMDD)
b. SIGNATURE
In the event you are not the law enforcement agency with jurisdiction authority consistent with the offender's release address, please
forward these documents to the appropriate authority.
DD FORM 2791, APR 2003
REPLACES PREVIOUS EDITION AND DD FORM 2791-1, WHICH ARE OBSOLETE.
Reset

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2