EFTA00038390

New York State Intelligence Center Latham, New York 12110 REQUEST FOR INFORMATION FORM Main: FAX: Toll-free: DATE & TIME OF REQUEST I MEMBER/ANALYST ASSIGNED RICS Control #: Rank: Received/Entered By: Last Name: Date: Time: Tax / SS#: REQUESTOR'S INFORMATION Agency Name and Investigation Child NY03030C9 Command/Unit: Child Exploit T/F ORI: Type: Exploitation Workplace (Full Address): 26 Federal Plaza, New York, NY 10278 Last Name First Name: Ftankaitle: Detective Tax # NYPD Only: SSN: Date of Appointment: 08/30/1993 Office #: Fax A: Pager/Cell#: Pin: TZS/Pct. Of Occ.: CompIft: Case#: 2017-212 Conferred w/ Requestor Date: Time: Supervisor's Rank/Full Name: LT Phone Number: SUBJECT INFORMATION Last Name: Borgerson First Name: Scott Middle: G Aliases: DOB: Age: 44 Sex: M Race: W POB: Gang Name: Bldg# Street: Apt: City: State: ZIP Code: Tel# SSN# Driver License#: S State/Country: MA Arrest: FBI#: NYSID#: Other State SID#: BUSINESS LOCATION & FINANCIAL INFORMATION Business Bldg: Street: Name: City State: Zip Code Tel#: Last Name: First Name: (Circle One) Owner/Mgr/Employee Tax ID#: Financial Institution: Account Type: VEHICLE INFORMATION Plate it: State/Country: Year: Make: Model: No. Doors/Body Style: Color: Gray VIN#: REMARKS What have you (Requestor) done? What needs to be done by NYSIC personnel? I am requesting a CIAS search of the above named male for the past one year. EMAIL Request to NYSIC: ciu n csic.n . ov OR FAX Request to NYSIC: (You MUST call to verify that your FAX was received!) EFTA00038390