House Oversight Form Template with No Specific Allegations

_ @ E Vv. 12-19-06) Squad supervisor approval (please initial) Fite Number O Oo Bankruptcy Fraud oO Computer Fraud/Abuse O Corruption of Public Official Money Laundering Sub Invest Asst by FO(s) A. Complaint / Information/ Indictment (Federal [jLocal Complaint Date: Check if Civil Rico Complaint O (2 Intemational information Date: Indictment Date: . Locate / Arrest [Federal [JLocal ([] International - Subject Priority: OA OB Oc Locate Date: Arrest Date: (CF Subject Resisted Arrest (D Subject Arrested was Armed . Summons Date: (Federat [Fj Local » Recovery / Restitution / PELP X (Federal [JLocal {7 International Recovery Date: Code * v Amount $ Code*. vy =Amount $ Restitution Date; (] Court Ordered ([] Pretrial Diversion Code*__yv =Amount $ PELP Date: Code*__ vy = Amount $ . Hostages(s) Released Date:, Released by: [] Terrorist (] Other Number of Hostages: P, Subject Information - Required for all blocks excluding block D (Recovery/PELP), blocks E, I, L and N [ace* | sex | Detain | __ Sol Seariyo (evan) —_| ES A Asian Organized Crime (AOC), Nalian Organized Cnme (!0C), Russian/Easlern European, Caribbean, or Nigerian Organized Cnme Group = 0 ict IsvUOnvICctio ony: Subject related to. an LCN, Complete FD-515a, Sida 1 Blacks A-E mandatory, F-H as appropriate, E-MM- 1 oF 062 | Accomplishment Report (Accomplishment must be reported and loaded into ISRAA within 30 days from date of accomplishment) 2. Helped, minimally 1A Rate FO T Aircraft Asst. | [censen en |_| | | ecsurst. | | Eng. Tape Ex. || Legats Asst. Evid. Purchase | | F. Conviction (C Federal [1 Local Conviction Date: C1 International Subject Description Code *( ye For 6F, G, H-Include Agency Code (1 Felony or (J Plea or State: (C1) Misdemeanor (1 Trial Judicial District: G. U.S. Code Violation Required for sections A, B, F and J (Federal Only) Title Section # Counts H. Sentence Date: Sentence Type: 1 ' Years__——. Months Months, In Jail: Suspended: Years Probation: Years, Fines; - $ |. Disruption/Dismantlement: “ Disruption Date: Dismantlement Date: Completion of FD-515a Side 2 Mandatory Investigative Assistance or Technique Used 4. Used, but did not help For Sub, Invest. Assist. by other FO(s) indicate A, B, C, D for corresponding FO AT Rate FO 1AT fisorewsm| | [uco-naisoal | = P[renexsers | Mil cavcr carl | BBE conouer [| | Photo cover | = [rovaesh |_| P—[etsunrise| | | seuen Waren stow ioney |_| fen. Fessoc| | |socasst | Bc. saréain| | [Phone Ta Ree| | Frown [| |uco-Grout | i Foctaroasst |__| [tsb oh.exam| | _fuco- ere] Months________., Date Prepared OH, Date Loaded Date Loader’s Initials 3. Helped, substantially 4. Absolutely essential Rate FO IAT ree | ; BB crimis intel Asst] —_| fe Crisis Neg,- Fed | | Sav-!TC | | JFi.Mon.-17¢ | | ronraitapse| | | J. Civil Rico Matters Date: Also complete “Section G” Other Civil Matters Date: Judgment Judicial Outcome_______—_—®x Amount $ Suspension: Years Months K. Administrative Sanction Date: Subject Description Code Type: Length: []Bevamen I Permanent Debarment Injunction or Year Months L, Asset Seizure Date:. Asset Forfeiture Date: CATS # Mandatory Circle below 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 not indicate $ in Section D O. Child Victim Information Child located / identified’ Date: b/ Bo) oY beLiving (D Deceased Code * 0 Subject related to an OC/Drug organization, a VCMO Program National Gang Stralegy targel group, or a VCMO Program National Priority fnilialive target group - Complete FO-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. e See codes on reverse side, Serial No. of FD-515 ¥ Requires that an expianation be attached and loaded into ISRAA for recovery over $1 m and PELP over $5 m, disruption, dismantlement, and drug seizures. BlE- MM -~ (o80b2~ 18 ¥ HOUSE_OVERSIGHT_021588