Epstein Secrets

. Marital Status 18.a. Country Single O Married O Divorced O Widowcd LovAiz. I 12. Have you previously filed Form 1-765? OYes ENo 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? @Yes O No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. I

a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Print Name and Title) (Date) (Monitoring Case Agent's Signature) (Date) (Print Name and Title) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-03

l Status gs) Single 0 Married 0 Divorced K Widowed 18.a. Country 12. Have you previously filed Form I-765? 18.b. Country Oyes JNo 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? @Yes 0 No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. I

itoring agent must be designated in the appropriate jurisdiction. —1 I (Monitoring Group Supervisor's Signature) (Date) (Print Name and Title) (Monitoring Case Agent's Signature) (Date) (Print Name and Title) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-03

your father's birth name. 16.a. Family Name (Last Name) 16.b. Given Name (First Name) Mother's Name Provide your mothers birth name. 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? 0 NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you ans

e Agent, a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Print Name and Title) (Monitoring Case Agent's Signature) (Print Name and Title) (Date) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Fenn 73-03

your father's birth name. 16.a. Family Name (Last Name) 16.b. Given Name (First Name) Mother's Name Provide your mothers birth name. 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? 0 NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you ans

a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Date) (Print Name and Title) (Monitoring Case Agent's Signature) (Print Name and Title) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Font 73-031 (4/11)

arital Status 18.a. Coun Eraingle K Married K Divorced K Widowed 12. Have you previously filed Form I-765? 18.b. Country ❑Yes E'No 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? ErYes K No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14.

a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Date) (Print Name and Title) (Monitoring Case Agent's Signature) (Date) (PrintRame and Title) Request for Continued Presence FOR OFFICIAL USE ONLY! LAW ENFORCEMENT SENSITIVE ICE Form 73-031