House Oversight FD-515 Form Template with No Specific Allegations

wn : FD-515 (Rev. 12-19-06) Squad supervisor approval fease initial) Accomplishment involves: (check ail that apply) Drugs 0 AFugilive O Bankruptcy Fraud C Computer Fraud/Abuse oO Corruption of Public Official Money Laundering O Sub Invest Asst by FO(s) Asst. FO(s) AB. CG, OD. | A. Complaint / Information/ Indictment (Federal ([]Local Complaint Date: CJ Intemational Check if Civil Rico Complaint 1 Information Date: Indictment Date: B. Locate / Arrest (Federal [Local SubjectPriorty. OA OB (1c Locate Date: [J Intemational : Arrest Date: (7) Subject Resisted Arrest (J Subject Arrested was Armed C, Summons Date: (1) Federal [J Local D. Recovery / Restitution / PELP X C Federal [JLoca! [7] International Recovery Date: Code * v Amount $ . Code*_ =v) =Amount $ Restitution Date; (Court Ordered [[] Pretrial Diversion Code * v Amount $ PELP Date: Code ° ¥ Amount $ E. Hostages(s) Released Date: Released by: [] Terrorist (1) Other Number of Hostages: File Number S-MM -1oK¥oe2 Accomplishment Report (Accomplishment must be reported and loaded into ISRAA within 30 days from date of accomplishment) 41. Used, but did not help 2. Helped, minimally Rate FO Rate FO 1A) IAT Fin.Analyst [| -[[eonsenon [| F. Conviction (Federal (C1 Local Conviction Date:, (J International Subject Description Code (.)® For 6F, G, H-Include Agency Code (7) Felony or (Plea or State: C Misdemeanor O Trial Judicial District: G. U.S. Cade Violation Required for sections A, B, F and J (Federal Only) Title Section # Counts H, Sentence Date: Sentence Type: ' In Jail: Years. Months, Suspended: Years. Months. Probation: Years Months Fines: $ |. Disruption/Dismantlement: Vv Disruption Date: Dismantlement Date: Completion of FD-515a Side 2 Mandatory investigative Assistance or Technique Used For Sub. Invest. Assist. by other FO(s) indicate A, B, C, D for corresponding FO T ; fist. ries] |_| J Aircrattass. | | | Pen Registers | | . | computer {| = | Photo Cover | | search Waren] | | |socassh | Fieacwinee |_| [uco-crout | _| fsb. BW. Exem| | | uco-Grovptt| | Date Prepared Of, (s] Xx Date Loaded __& Date Loader’s Initials 3. Helped, substantially 4. Absolutely essential Rate FO JA Rate FO (AT + Juco-NatBack| | [caver v-cap] IMME 10 Wanted Fiver Bp Ccimsis tt Asst] | Bcrisis Neg.-Fed] | | BerTasct, | | Beue-ro | | sav-ire | - a Coo |__| |__| | || Ft. Mon. - ITC OFCICID For. Lang Asst. ppp J. Civil Rico Matters Date: Also complete “Section G” Other Civil Matters Date: Judgment Judicial Outcome___ —_ —__ —_** Amount $ Suspension: Years Months K. Administrative Sanction Date: Subject Description Code Type: Length: A Suspension [[] Permanent Debarment or Injunction Year. Months L. Asset Seizure Date:. Asset Forfeiture Date: CATS # Mandatory __E Circle befow one of the three asset forfeiture: Admin, Civil Judicial, or Criminal Do not indicate $ value in Section D M. Acquittal/ Dismissal/ Pretrial Diversion (Circle one) Date: N. Drug Seizures “Date: Drug Code ® Weight FDIN . Do nat indicate $ in Section D O. Child Victim Information Child located / identified Date: &[20/ oY btiving C] Deceased Code ° P, Subject Information « Required for all blocks excluding block D (Recovery/PELP), blocks &, I, L and N Pte | Race® | Sex | Date of Birth Social Security No. (if available) For Indictments/Convictiq . Subject related to ad LCN, Asian Organized Crime (AQC}, Italtan Organized Crime (OC), Russian/Eastem European, Caribbean, or Nigerian Organized Cnme Group + Complete FD-515a, Side f Blocks A-E mandatory, F-H as appropriate, Subject related to an OC/Drug organization, a VCMO Program National Gang Strategy torgel group, or a VCMO Program National Priority Inilialive target group - Complete FO-5153, Side 1 Blocks A-C only. b6 b7C x Additional information may be added by attaching another form or a plain sheet of paper for additional entries. Serial No. of FD-545 « See codes on reverse side. [Od v Requires that an explanation be attached and loaded into ISRAA for recovery over $1 m and PELP over $5 m, disruption, dismantlement, and drug seizures. SIE -MU- (98062 - (Ke HOUSE_OVERSIGHT_021586