BP-5377.058 PRISONER REMAND CDFRM FEB 04 V.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS ARRESTING OFFICER WILL COMPLETE,ALL REQUIRED DATA ON THIS FORM PRIOR TO COMMITTING TO MCC/MDCs. Name: AKAs: Register Number Middle U R Race (C,heck) B /W A I - Sex/ (Check) /em __F Ethnic Origin (Check) Hispanic or/Other D.O.B. SSN: r'/if: INS: Other: CHARGES CHECK-CATEGORY OF CHARGES(S): .FELONY . MISDEMEANOR • CIVIL CONTEMPT • - MATERIAL WITNESS...... M i.' Se VU-Li t .- t- cc itA p OTHER NARRATIVE: Title: USC: NARRATIVE: Title: USC: Date of Offense: Date of Arrest:.- Place of_ Arrest . State of Birth Country.ot Birth Citizenship Current Addrese Zip Code.:. Height Ft: In: Weight . Hair' . Eyes. Scars' L. Marks / Tattoos Injuries /Medication Arraigned iN Sentenced Remarks: Remanding Official (Name) Sign Print Print Emergency, Contect:(Namer Address, Phone Number) Special. Handling: _Y or Agency/District Agency/District & o f *Receiving Official (Name): sign Print Date /. Time' 1 CI I I C\ re Phone/24 Hour Number Phone/24 Hour Number Date / -Time Relear Official- (Name) Sign ( ... . ;)I..— Print.S..,44--..-. Sentry Load Data: (Must Initial) - Name Search Completed by: - Llearance/Separate Checked- by: (OPTIONA ARS Code Staff Init. Add AKA' Create Cash- Account - Deposit Cash. Amt. Detainers Court Clothing Bag I Original-for ISM.aS Remanding-Removal receipt; Copy-for. Control. a%Removal.Receipt 4NCICW0opy-For Removing,Officiel; Copy-for Contr61 as Remanding Receipt (Inmate); Copy-INS-Alien in Custody.-- • 4Thistform may be replicated via- WM. This form replaces BP-5377 (58). and BP-377(5B):of JUL. 91 EFTA00120669

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