House Oversight Form Template with No Specific Actors or Allegations

5 Vv, 12-19-06) © Accomplishment Report ® Date Prepared 29/0 S quad supervisor approval (Accomplishment must be reported and loaded into Date Loaded please initial) ISRAA within 30 days from date of accomplishment) Date Loaders Initials Investigative Assistance or Technique Used 41. 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 Rate FO iw Rate FO IAT IAT T Finwvnatyst | JM usp. rtisu | | fuco-natpack] | Aircraft Asst. | |] Pen Registers || BB vcavervicap] | [computer [| | Photo Cover || BB criovns tntet Asst] | | [eonsenion_| | ID cic Wen Fal _| eusur/risc| || scorcnwarant| fevsun sti | fl stow ney [MM err ast. | (MF Suppor | socass | | [swatteom | MM sav-irc | Accomplishment involves: (check all that apply) File Number O Computer Fraud/Abuse Corruption of Public Official Money Laundering Sub Invest Asst by FO(s) = [|e Pucose| ll Phone To os | fiasco exan| | _|vco-crunit] — fvonraicabes| | |__| J, Civil Rico Matters Date: Also complete “Section G” Other Civil Matters Date: F, Conviction ()Federal [Local [(] Intemational Conviction Date: A. Complaint / Information/ indictment ()Federat [Local [1 Intemational Complaint Date: Check if Civil Rico Complaint 0) Suijedt Bstefiplior pie *——* ae ; Judicial Outcome OX Information Date: For 6F, G, H-Include Agency Code Amount $ Indictment Date: = ae or oe Suspension: Years -_ Months ea or tial B, Locate / Arrest State: Judicial District: K. Administrative Sanction Date: (Federal [JLocat [1] International Subject Description Code ¥ ; i G, U.S, Code Violation Type: Length: Subject Priority: [JA OB []c Required for sections A, 8, F and J Suspension [[] Permanent Locate Date: (Federal Only) Debarment or Arrest Date: Title Section # Counts Injunction Year Months (C1 Subject Resisted Arrest (1) Subject Arrested was Armed L. Asset Seizure Date: Asset Forfeiture Date: CATS # Mandatory __EE Circle below one of the three asset forfeiture: Admin, Civil Judicial, or Criminal Cc. Summons Date: (Federal [J] Local D. Recovery / Restitution / PELP X [] Federal [JLocal [J International Recovery Date: Code * v Amount $ Code* sey =Amount $ Restitution Date: Do not indicate $ value in Section D H. Sentence Date; Sentence Type: . M. Acquittal/ Dismissal/ Pretrial Diversion (Circle one) Date: Months___ Months______ In Jail: Years. Suspended: Years. N. Drug Seizures “ ‘Date: (J Court Ordered [[] Pretrial Diversion Probation: Years Months__. Drug Code ® : Code ° Y Amount $ Fines: $ Weight _______. Code PELP Date: FDIN ater z Do not indicate $ in Section D Code * v Amount $ 1, Disruption/Dismantlement: V E, Hostages(s) Released Date:. ; Disruption Date: Released by: CJ Terrorist [ Other 0. Child Victim Information Child located / identified Date: O&S/Zo oy” Dismantlement Date: PRiving (7) 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, Il, Land N tice] sox [7 oa gan [ Se Seer (rvaany | or y—~—<“‘<i<‘ish UU [_] Subjectretatedto an Asian Organized Crime (A , Haltan Organized Cnme (IOC), Russian/Eastern European, Caribbean, or Nigerian Organized Crme Group - Complete FD-515a, Side 1 Blocks A-E mandatory, F-H as appropriate. O Subject related to an OC/Drug organization, a VCMO Program Nalional Gang Slrategy targot group, or a VCMO Program National Priority Inilialive targel group - Completa FD-515a, 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. Serial No. of FD-515 e See codes on reverse side, | sd ¥ Requires that an explanation be attached and loaded info ISRAA for recovery over $1 m and PELP over $5 m, disruption, dismantlement, and drug seizures. AEMY - (0062-19 be b7C¢ HOUSE_OVERSIGHT_021614