Dd Form 2791 - Notice Of Release/acknowledgement Of Convicted Sex Offender Registration Requirements Page 2
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3NOTICE OF RELEASE/ACKNOWLEDGEMENT OF CONVICTED SEX OFFENDER
REGISTRATION REQUIREMENTS
SUPPLEMENTAL LETTER
(Explain to the offender the requirements for registration in the identified jurisdiction.
Have the offender read the information carefully, then initial the block adjacent to the right of each statement.)
(Offender's Initials)
1. I,
,
,
,
,
(Full Name - Last, First, Middle)
(Grade/Rank)
(Branch)
(Social Security Number)
was convicted for the commission of (a) sexual offense(s) that (did or did not) include a sentence to
(Circle one)
confinement, and require(s) me to register as a sex offender.
2. I acknowledge that I have been informed that I will be physically released from confinement on or about
.
(YYYYMMDD)
3. I acknowledge that I have been informed that if I am retained in the armed forces, I must register as a sex
offender with both military and civilian law enforcement agencies with jurisdiction over the installation, and my
to my assigned unit.
residence upon my physical arrival on
(YYYYMMDD)
4. I certify that upon release from confinement or military service I will reside at the following address:
(Street, Apartment Number, City, State and ZIP Code)
5. I hereby acknowledge that I was informed that upon my release from confinement or military service, I am
subject to registration requirements under the Sex Offender Registration and Notification Act (SORNA) as a
sex offender within 72 hours in any state, territory, or tribal nation, in which I will reside, be employed, carry on
a vocation, or be a student.
6. I understand that if I am awaiting appellate review/administrative actions by my Service component, I am
required to register with the state and local law enforcement agencies until the appellate process is complete,
regardless of my location.
7. I understand that I must also register at least 21 days prior to any international travel.
8. I understand that I must contact the office that follows, to ensure that sex offender registration requirements
are met:
(Organization, Address (Include ZIP Code), and Telephone Number)
9. I understand that should the office listed in block 8 not be the correct point of registry for the jurisdictions in
which I plan to reside, be employed, or go to school, I will seek out and register at all appropriate offices.
10. I acknowledge I have been informed that the sex offender registry of the jurisdiction in which I will reside upon
release from confinement or military service is being provided written notice about the offense(s) for which I
was convicted, that I am subject to a registration requirement as a sex offender, and the date I was released
from confinement or military service.
11. I acknowledge I have been informed that every change in my local address must be reported in the manner
provided by state or tribal law.
12. I acknowledge I have been 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.
13. I acknowledge I have been advised and understand that if I do not register and/or change or update such
information as required by a relevant state, tribal or territorial sex offender registration program, my failure to
comply with these requirements could result in such penalties as revocation of parole/MSR or prosecution
under Federal law (18 U.S.C. 2250), punishable by up to 10 years imprisonment.
14. Signed on this
day of
,
.
a. WITNESS:
b. OFFENDER:
(Signature)
(Signature)
(Print Full Name - Last, First, Middle Initial)
(Print Full Name - Last, First, Middle Initial)
Page 2 of 3 Pages
DD FORM 2791, MAR 2013
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