!LEASE PRINT OR TYPE ... Complete all sections.

!LEASE PRINT OR TYPE ... Complete all sections. SEXUAL OFFENDER/SEXUAL PREDATOR REGISTRATION FORM I FOR USE BY LAW ENFORCEMENT AGENCIES attach finporpdat card. phiRograph, and smells markers then available, and submit to IM Department of Justice. GERS &SIMI% 2.4 Floor. St. Thann,V1 00602 SECTION A — Type/Status SECTION B • Contributing Agency Information 14-Sex Offender - [ J Habitual Sexual Offender I 1 Sex Predator [ 1 New Registration [ 1 Modify Data Agency Name: Agency Address: Phone Number: ( ) Fax: ( ) Checked for Warrants: I 1 Local System [ J FCIC.NCIC SYSTEM CCH for Sex Offenses: [ J Yes [ 1No SECTION C • Registratiotnformation Name: erney 1 (fi-G, C Alias: SSN#:0/1 0%-1/41÷33Y /Alien If: Fist ( /hit* DOB: [ -CI Si POB: PG/ '1.), - VI Driver's License#: 0 0 0 0 c3 21-Q 3 ki Exp. Date: /- 2-0 if -- mom i v 0 WA' Race: “-, Sex: N HI: to WI r o Hair: Ot t ) Eyes: V Scars, Marks, Tattoos: Are You Registered as a Sex Offender in Another State: [ 1 NO [ ] YES If YES, which state: and at what LEVEL SECTION D - Residence a_ i Closest Living Relative .)-- ‘ 0.- Physical Address: 1-I IF t- Name: Stz:,It. r-I-Cs. Relationship: 1 -tle; Mailing Address: to 0 u IZAI Boots Address: (, o f >4 4, Temporary Address: Contact #: Home cmilltar Contact #: Home: Cellular . SECTION E • Employment [ J Employed [ J Unemployed Employer: T C Contact Person: Occupation: V=71.4. Telephone •Address: r , Par /J k7 Date Employment h.- lit -.. SECTION F: Vehicle, Trailer, Vessel, Etc. Description (Year/Make/ModeVColor Scheme) : 4- , A Ade) License Plate#: VIN#: SECTION G - Offense Information VICTIM w Adult [ ] Minor I J Acquitted by Reason of Insanity Date of Conviction Offense Committed Place of Conviction Court/Court No. AG No. —) / Di Pil Inr-TI DN... Fc• A IPA Y ,,, c,.: r- 01-ni-il,„; r c .. fi 0 (ic SECTION H • PLEASE READ CAREFULLY BEFORE SIGNING As a Sexual Offender or Sexual Predator (Title 14 V.I.C. § 1721.1731) you are required by law to abide by the following: I. Within five (5) working day of being placed under any type of supervision in the community you must use this form to register with (he V.I. Department of Justice. In the event you are moving to or returning to the USVI from another jurisdiction, you must register with the V.I. Department of Justice within five (5) days of first residing in or returning to the USVI. 2. In the event there is a change in your permanent or temporary residence after initial registration and any subsequent changes thereafter, you must notify the V.I. Department of Justice within three (3) days after arrival at your new residence. 3. In the event there is a change in your address outside the USVI, you must register your new address with the V.1. Department of Justice prior to departure and also register In your new jurisdiction within len (10) days after establishing residence there if the new jurisdiction has a registration requirement. 4. You are required to verify your address with the V.I. Department of Justice annually on the anniversary of your initial registration. II you were determined to be a sexually violent predator, you must verify your address with the V.1. Department of Justice every ninety (90) days after the dale of your initial release or commencement of parole. 5. Failure to comply with the above requirements shall subject you to a fine of not less than $3,000.00 or imprisonment for nol less than three (3) months or more than two (2) years, or both. Be Reminded that even if you may not be required to register under Virgin Islands Law, under Title I of the Adam Walsh Act entitled the 'Sexual Offender Registration and Notification Act 1SORNA), all intividuals convicted of a sex offense are required to register and keep their registration current in each jurisdiction where he or she resides, is an employee and is a student. FAILURE TO DO SO MAY SUBJECT YOU TO CRIMINAL PROSECUTION Registrant: I acknowledge that the above requirements as set forth have been explai tome. / . 9( I II t Witness: I certify abo that I specifically informed nd he indicate me an the o rider of his /her duties as have set forth mole 1 ndirg se duties. 6 a S e Regi li 0 I p 3 (O/A lum of R I nel r • 1 7e( it Print N Data Printratmli Dale EFTA00304441