House Oversight Form Detailing Investigation Reporting Requirements

@ e V, 12-19-06) Accomplishment Report Date Prepared {7 29 O g Squad supervisor approval (Accomplishment must be reported and loaded into Date Loaded ['20/ Os (please initial) ISRAA within 30 days from date of accomplishment) Date Loader’s Initials Investigative Assistance or Technique Used 1, Used, but did not help 3. Helped, substantially 2, Helped, minimally 4, Absolutely essential For Sub, Invest. Assist. by other FO(s) indicate A, B, C, D for corresponding FO IAT Rate FO IAT Rate FO WAT Rate FO IAT [Fn toast | WMiMst.rovse | | [uco-nawoal | Polygraph Crisis Neg.- Fed CART Accomplishment invoives;: (check all that apply) File Number O O Bankruptcy Fraud O Computer Fraud/Abuse O oO O O Corruption of Public Official Money Laundering Sub Invest Asst by FO(s) Tersurvriso| | | scocn waren] — [[uc0-creupr | [eee fis. ow.exen| | _|vco-crowi| venraitabex) | | J. Civil Rico Matters Date: Also complete "Section G” Other Civil Matters Date: F, Conviction (Federal [Local [] Intemational Conviction Date: A. Complaint / Information/ indictment (Federal [JLlocat [7 International Complaint Date: . . ry a —_——* Check if Civil Rico Complaint Suh) pe Desiripllon ads *(—__ seinen Judicial Outcome_____ OX Information Date: For 6F, G, H-Include Agency Code Amount $ indictment Date: 5 ed oF 5 al Suspension: Years Months__, Plea or tia’ B. Locate / Arrest State: Judicial District: (Federal [Local {7 Intemational : Subject Priority OA O18 Oc Locate Date: K. Administrative Sanctlon Date: Subject Description Code ® Type: Length: Suspension [[] Permanent or G. U.S. Code Violation Required for sections A, B, F and J (Federal Only) Title Debarment Injunction Section # Counts Year, Months Arrest Date: (F Subject Resisted Arrest (] Subject Arrested was Armed L. Asset Seizure Date: Asset Forfeiture Date: CATS # Mandatory —_ Circle below one of the three asset forfeiture: Admin, Civil Judicial, or Criminal C. Summons Date: [Federal [[] Local . Recovery / Restitution / PELP X (Federal [JLocal [] International Recovery Date: Code * vy Amount $ Code*___.y Amount $ Restitution Date: Do not indicate $ value in Section D H. Sentence Date; Sentence Type: . M. Acquittal/ Dismissal/ Pretrial Diversion t ‘ (Circle one) Date: Months____ Months______. In Jail: Years, Suspended: Years. N. Drug Seizures “ Date: (Court Ordered [Pretrial Diversion Probation: Years Months___ Drug Code ® : Code*___s v= Amount $ Fines: $ Weight ________. Code PELP Date: FDIN ae y Do not indicate $ in Section D Code * v Amount $ |. Disruption/Dismantlement: E. Hostages(s) Released Date: . Disruption Date: Released by: [1] Terrorist [1 Other 0. Child Victim Information Child located / identified cue. 0B ofray Dismantlement Date: Pr riving _ U)Deceased Number of Hostages: Completion of FD-515a Side 2 Mandatory P, Subject Information - Required for all blocks excluding block D (Recovery/PELP), blocks E, I, Land N ————— EE eee ee ee eee For Indictments/Convictions only: O Subject related to an LCN, Asian Organized Crime (AOC}, tlalian Organized Crime (10C), Russlan/Eastern European, Caribbean, or Nigerian Organized Crime Group - Complete FD-515a, Side 1 Blocks A-E mandatory, F-H as appropriate. oO Subject related to an OC/Drug organization, a VCMO Pragram National Gang Slrategy targel group, or a VCMO Program National Priorily tnitialive target group - Complete FO-5153, Side 1 Blocks A-C only. x Additional information may be added by attaching another form or a plain sheet of paper for additional entries. Satta! oso) SE-ais e See codes on reverse side. | —“C—SY 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. S/E —- HA O§0e2- (Fz HOUSE_OVERSIGHT_021612