NOTICE OF RELEASE/ACKNOWLEDGEMENT OF CONVICTED SEX OFFENDER
REGISTRATION REQUIREMENTS
1. TO
STATE LAW ENFORCEMENT
LOCAL LAW ENFORCEMENT
STATE SEX OFFENDER REGISTRATION OFFICIAL
U.S. MARSHALS - NATIONAL SEX OFFENDER TARGETING CENTER
a. ADDRESS (Include ZIP Code)
b. DATE (YYYYMMDD)
The Department of Defense is notifying your office of the release of an offender who, based on available information, was convicted of a covered
sex offense under 42 U.S.C. 16911, et seq., 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 POC with the facility of release who is identified below. As used in this form, state also
includes tribe or territory.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 951 (Note); 18 U.S.C. 2250; 42 U.S.C. 16911 et seq.; DoDI 1325.7; and E.O. 9397.
PRINCIPAL PURPOSE(S): To record the offender's acknowledgement of receiving sex offender registration notice and information pertaining to this
requirement, and to document an offender's expected place of residence following release.
ROUTINE USE(S): To state and local law enforcement authorities for the purpose of notification that a sex offender will be residing in a local
community and for the purpose of registering the individual as a sex offender.
DISCLOSURE: Voluntary; however, failure to provide requested information may result in the denial of your request for parole or delay your release
from confinement or military service. Required to provide this information to Federal, state and local law enforcement agencies, in accordance with
Federal law (18 U.S.C. 2250).
3. DATE OF BIRTH
4. SOCIAL SECURITY
5. DISCHARGED
6. APPELLATE REVIEW
2. NAME OF OFFENDER
(Last, First, Middle)
NUMBER
(YYYYMMDD)
(X one)
(X one)
YES
NO
YES
NO
7. CURRENT AND PRIOR CRIMINAL HISTORY OF SEXUAL OFFENSE(S)
d. VICTIM'S AGE/
b. DATE OF
a. SPECIFIC OFFENSE TITLE AND DESCRIPTION
CONVICTION
DATE OF BIRTH
c. PLACE OF CONVICTION
(5 words or more)
(YYYYMMDD)
(YYYYMMDD)
8. MAX REL DATE
9. RELEASE CONDITIONS OR RESTRICTIONS
(YYYYMMDD)
10. FACILITY OR COMMAND RELEASING OFFENDER
a. NAME OF FACILITY OR COMMAND
b. ADDRESS (Include ZIP Code)
11. CORRECTIONAL FACILITY OR COMMAND POINT OF CONTACT (POC)
c. TELEPHONE NUMBER
a. NAME (Last, First, Middle Initial)
b. ADDRESS (Include ZIP Code)
(Include
Area Code)
12. 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.
Page 1 of 3 Pages
DD FORM 2791, MAR 2013
PREVIOUS EDITION IS OBSOLETE.
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