Dd Form 2716-1 - Dod Certificate Of Supervised Release

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DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
(Last, First, Middle)
(Social Security Number)
(Date - YYYYMMDD)
being eligible for supervised release under the terms and conditions prescribed by the prisoner's respective branch of service, will be
released on community supervision from the
Supervisee's Facility Address (Facility Name/State/ZIP Code)
provided that the supervised release plan for residence, employment, and U.S. Probation Officer has been completed and the
supervisee complies with the provisions and conditions prescribed in this Certificate of Supervised Release and further provided that
all conditions set forth by the respective branch of service and facility commander are met and the supervisee continues to perform
satisfactorily until release from supervision.
The term of supervision hereby granted will become effective on
and will expire on
(Date - YYYYMMDD)
(MaxRel Date - YYYYMMDD)
unless sooner suspended or revoked for violation of its conditions or otherwise terminated by competent authority.
Signed
(Chair, Parole and Clemency Board)
ENDORSEMENT
The above named individual was released from confinement and placed on
(Mandatory Supervised Release or Parole)
the
day of
,
.
Dated
Signed
(YYYYMMDD)
(Commander of Correctional Facility)
DISTRIBUTION
File completed original in the prisoner/supervisee's Correctional Treatment Folder (facility). Provide a copy to the supervisee; send
one copy to the supervisee's probation officer; and one copy to the supervisee's Clemency and Parole Board.
DD FORM 2716-1, MAR 2013
Page 1 of 4 Pages
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X

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