Dd Form 2791 - Notice Of Release/acknowledgement Of Convicted Sex Offender Registration Requirements Page 3
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3INSTRUCTIONS FOR COMPLETING DD FORM 2791
THE AGENCY THIS DD FORM 2791 IS BEING
CORRECTIONAL FACILITY OR COMMAND POINT OF
FORWARDED TO
CONTACT (POC)
Block 1. Identify the type of law enforcement agency
Block 11.a. Enter last name, first name, and middle initial of
notification is being sent.
facility POC.
Block 1.a. List the agency address, to include city, state
Block 11.b. Enter address of facility POC, to include ZIP
and ZIP Code.
Code.
Block 1.b. Enter the date the form is being filled out
Block 11.c. Enter the telephone number of facility POC,
(YYYYMMDD - Year/ Month/Day).
including area code.
NOTE: The Privacy Act Statement should be read by
FACILITY COMMANDER OR COMMANDER RELEASING
all applicable offenders.
OFFENDER
Block 12.a. Enter last name, first name, and middle initial of
OFFENDER'S PERSONALLY IDENTIFIABLE
correctional facility commander or the commander releasing
INFORMATION
the offender, including rank or title.
Block 2. Enter the applicable offender's last name, first
Block 12.b. Facility commander's signature required or the
name and middle name.
commander releasing the offender.
Block 3. Enter the applicable offender's date of birth
Block 12.c. Enter the date the form was signed (YYYYMMDD
(YYYYMMDD - Year/Month/Day).
- Year/Month/ Day).
Block 4. Enter the applicable offender's complete Social
Security number.
PAGE 2, SUPPLEMENTAL LETTER
DISCHARGED
NOTE 1: Have offender read the information below
Block 5. Mark (X) the appropriate block (Yes or No) for the
carefully, then initial the block adjacent to the right of
offender's affiliation with the military service.
each statement.
APPELLATE REVIEW
Block 1. Enter the offender's full name, grade/rank (if
Block 6. Mark (X) the appropriate block (Yes or No) if
applicable), branch of Service, Social Security number, and
offender is awaiting or undergoing the appellate review
select the appropriate response to indicate if the conviction(s)
process.
included a sentence to confinement.
CURRENT AND PRIOR HISTORY OF SEXUAL
Block 2. If applicable, annotate the date the offender is
OFFENSE(S)
physically being released from the correctional facility.
Block 7.a. List all current and prior criminal history of
sexual offenses (use brevity and conciseness in this limited
Block 3. If applicable, annotate the date the offender will
space).
report to his/her unit of assignment.
Block 7.b. Enter the date of conviction (YYYYMMDD -
Year/Month/Day).
Block 4. Enter the complete residence address including the
Block 7.c. Enter place of conviction (installation or city and
city, state and ZIP Code.
state).
Block 7.d. Annotate the age and date of birth
Block 8. Enter the name of the law enforcement agency and
(YYYYMMDD - Year/Month/Day) of the victim(s). It is
the complete address (including city, state and ZIP Code) and
important that the age of the victim(s) associated with the
telephone number (including the area code and extension, if
offender are annotated of not just minors, as the definition
applicable) where the offender is required to report for
of a minor may vary from jurisdiction to jurisdiction. If this
registration upon release from confinement or the Service
information is not in the court martial documents, ask the
Component.
prisoner.
Block 14. Enter the date the offender signed the
MAX REL DATE
Supplemental Letter. The witness and the offender sign the
Block 8. Enter offender's maximum release date from
letter and legibly print their names on the appropriate line
confinement (if applicable).
below their signatures. If an offender refuses to sign the
letter, write "OFFENDER REFUSED TO SIGN" on the
RELEASE CONDITIONS OR RESTRICTIONS
offender's signature line, notify the Commander, and process
Block 9. Annotate reason for release (i.e., expiration of
the form unless instructed otherwise.
sentence, parole, or MSR).
FACILITY OR COMMAND RELEASING OFFENDER
Block 10.a. Enter the complete correctional facility name.
Block 10.b. Enter the complete address of the correctional
facility location that the offender is being released from,
including city, state and ZIP Code.
Page 3 of 3 Pages
DD FORM 2791, MAR 2013
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