House Oversight Form FD-515a Submission Template

S SisiPev. 12-19-06) “Squad supervisor approval (please. initial) Accomplishment Report (Accomplishment must be reported and loaded into ISRAA within 30 days from date of accomplishment) Accomplishment involves: 4. Used, but did not help (check all that appl File Number : Orgs ED (SIE=mm=(0k Oz 2, Helped, minimally A Fugitive O Bankruptcy Fraud C) IAT Rate FO Computer Fraud/Abuse O ; | Fin.Analyst |_| Corruption of Public Official BM Aircrattass. |_| | _Squad__| rest FO)_____] (PCGUAL Pe | , Bae Eng. Tape Ex. A. Complaint / Information/ Indictment (Federal [Local Complaint Date: F. Conviction Cl Federal [Local Conviction Date: (1 Intemational CD International Check If Civil Rico Complaint [1] Subject Description Code e (——__-_)* For 6F, G, H-Include Agency Code (Felony or (Plea or State: Information Date: (J Misdemeanor 0 Triat Judicial District: Indictment Date: . Locate / Arrest (Federal [)Local (1 International: Subject Priority: (JA [8 [Jc Locate Date: G. U.S. Code Violation Required for sections A, B, F and J (Federal Only) Title Section # Counts Arrest Date: (J Subject Resisted Arrest ( Subject Arrested was Armed . Summons Date: (J Federai (J Local . Recovery / Restitution / PELP X Federal [LJLocal = [7] International | | Recovery Date: | : H. Sentence Date: Sentence Type: Code * v Amount $ Code*_ v= Amount $ | , Restitution Date: a (Court Ordered [] Pretrial Diversion Code * yY Amount $ PELP Date: Code * Months. Months___ Months__ In Jail: Years. Suspended: Years. Probation: Years, Fines: $ v Amount $ |. Disruption/Dismantlement: v | | E. Hostages(s) Released Date: . ' ! Disruption Date: Released by: [1] Terrorist (1) Other Dismanttement Date: Number of Hostages: Completion of FD-515a Side 2 Mandatory P, Subject Information - Required for all blocks excluding block D (Recovery/PELP), blocks E, |, Land N Investigative Assistance or Technique Used For Sub. invest. Assist. by other FO(s) indicate A, B, C, D for corresponding FO IAT | [Pen Resistors || | ehotocover |_| |_| Search Warrant | [socAss. | Tech. Ag/Equip. [invewinto [| | | UCO - Group! Date Prepared OF 24 y Date Loaded b6é Date Loader’s Initials b7C bT7E 3. Helped, substantially 4. Absolutely essential Rate FO 1A Rate FO AT ° | Juco-narsoa | ; ucaver vicar] | Biss Non Fe Burro | [eee] tt J. Civil Rico Matters Date: Also complete “Section G” Other Civil Matters Date: Judgment Judicial Outcome___.___ OX Amount $ Suspension: Years Months. K. Administrative Sanction Date: Subject Description Code Type: | Length: . Suspension ([] Permanent Debarment or Injunction Year Months L. Asset Seizure Date: Asset Forfeiture Date: CATS # Mandatory ___SE 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 0. Child Victim Information Child located / Identified Date:_O of opeay Ph riving (7) Deceased : [| Cade *, [ Racet [Sex [bsborpin Ses oawy no avioby | Po Os Subject related fo an LCN, Asfan Organized Crime (ACC}, Italian Organized Cnma (!0C), Russlan/Eastern European, Caribbean, or Nigerian Organized Came Group - Complete FD-515a, Sida 1 Blocks A-E mandatory, F-H as appropriate. Subject related to an OC/Drug organization, a VOMO Program National Gang Slrategy targel group, or a VCMO Program National Priority Initiative targel group - Complete FD-515a, Side 1 Blocka 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 v Requires that an explanation be attached and loaded into |SRAA for recovery over $1 m and PELP over $5 m, disruption, dismantlement, and drug seizures. 3/E-HM -(0§062- (fe HOUSE_OVERSIGHT_021616