Dd Form 2716-1 - Dod Certificate Of Supervised Release Page 3

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DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
SUPERVISEE NAME (Last, First, Middle Initial)
SOCIAL SECURITY NUMBER
4. ADDITIONAL CONDITIONS AND STATEMENT OF UNDERSTANDING
I understand that release on supervision is contingent upon full disclosure of all of my conditions of release to my supervising U.S.
probation officer if they do not yet have a copy, and complying with all instructions of my supervising U.S. probation officer, and:
(NOTE: Clemency and Parole Boards will insert additional conditions of release.)
I thoroughly understand the foregoing additional conditions and solemnly promise to abide by them. I also understand that if I violate
any of the additional conditions, such a violation will be considered a violation of the basic supervision agreement.
(Signature)
(Date - YYYYMMDD
(SSN)
(Witness Signature)
(Typed Name/Grade)
(Date - YYYYMMDD)
DD FORM 2716-1, MAR 2013
Page 3 of 4 Pages

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