Dd Form 2716-1 - Dod Certificate Of Supervised Release Page 4
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4DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
5. APPLICABLE ONLY IF THE APPELLATE REVIEW OF THE COURTS-MARTIAL SENTENCE IS NOT COMPLETE
a. I voluntarily apply for excess leave without pay and allowances to become effective in the event of expiration of my term to
confinement prior to completion of appellate action on my court-martial sentence. I understand that for pay purposes,
I am in excess leave status during the period of supervised release, except to the extent I may be entitled to pay and allowances for
accrued leave which was not forfeited by my court-martial sentence.
b. I agree not to wear the military uniform following release on supervision.
c. I understand that in the event my court-martial sentence is set aside by appellate review, I may be ordered to return to an active
duty status.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C.
952, P.L. 90-377, and E.O. 9397.
PRINCIPAL PURPOSE(S): To certify an offender for Supervised Release from confinement, notify the individual of the Conditions
of Supervised Release, and record the individual's release from confinement and placement on Supervised Release.
ROUTINE USE(S): To the Department of Justice, in instances where the prisoner is incarcerated in a Federal Bureau of Prisons
facility, and to inform U.S. Probation Officers and the Administrative Office of the U.S. Courts of the Conditions of Supervised
Release.
DISCLOSURE: Voluntary; however, failure to provide the requested information as required in block 6a. may result in denial or
revocation of Supervised Release.
6. PRISONER CERTIFICATION.
I have been notified of, read and understand the foregoing conditions. I
accept
do not accept Supervised Release.
a. PRISONER SIGNATURE
b. DATE (YYYYMMDD)
7. WITNESS
a. NAME
, GRADE, TITLE
b. SIGNATURE
c. DATE (YYYYMMDD)
(Last, First, Middle Initial)
DD FORM 2716-1, MAR 2013
Page 4 of 4 Pages
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