5
Shared Docs
5
Same-Page
5 / 5
Mentions
ence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of inve
own ►YEW yo 3.d. State 3.e. ZIP Code Ny 10278 31 Province 3.g. Postal Code 3.h. Country N I reb 517:116 Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparers Fax Number 6. Preparer's E-mail Address 7.a. IR I am not an attorney or accredited representative but h
ence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of inve
vince 3.g. Postal Code 3.b. Country 2lo PED62AL PLAZA Flr. K NEW yotk 3.e. ZIP Code 10278 UNIT-6Th SikreS Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. xi I am not an attorney or accredited representative but
ence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of inve
Street Number and Name 3.b. Apt. K Ste. 3.c. City or Town 3.d. State 3.f. Province 3.g. Postal Code 3.6. Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address Preparer's Declaration By my signature, I certify, swear, or a
ence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of inve
Street Number and Name 3.b. Apt. K Ste. 3.c. City or Town 3.d. State 3.f. Province 3.g. Postal Code 3.6. Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address Preparer's Declaration By my signature, I certify, swear, or a
ence. Routine Use(s): The information collected on this form may be shared.with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of inve
IP Code N I D2 78 3.f. Province 3.g. Postal Code 3.h. Country 2a FED6_12AL PLA2A FIr. 0 Li N ran smerec Pireparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. g I am not an attorney or accredited representative but h
Entities connected to both Federal, State and Preparer

Jeffrey Epstein
PERSON
United States
LOCATIONLeon Black
PERSON
New York City
LOCATIONAlbany
LOCATION
New York
LOCATION
Homeland Security
ORGANIZATIONNew York Field Office
LOCATION
Department of Homeland Security
ORGANIZATIONU.S. Immigration and Customs Enforcement
ORGANIZATIONU.S. Citizenship and Immigration Services
ORGANIZATION
New York State
LOCATIONthe Social Security Administration
ORGANIZATION
Michael C.Green
PERSONthe NYS Division of Criminal Justice Services
ORGANIZATIONNew York State Division of Criminal Justice Services
ORGANIZATIONNational Crime Information Center
ORGANIZATIONParole and Law Enforcement Programs Unit
ORGANIZATIONRequesting Law Enforcement Agency
ORGANIZATIONMonitoring Group
ORGANIZATION