NOTICE OF RELEASE/ACKNOWLEDGEMENT OF CONVICTED SEX OFFENDER
REGISTRATION REQUIREMENTS
1. TO
STATE LAW ENFORCEMENT
LOCAL LAW ENFORCEMENT
STATE SEX OFFENDER REGISTRATION OFFICIAL
U.S. MARSHALS - NATIONAL SEX OFFENDER TARGETING CENTER
a. ADDRESS (Include ZIP Code)
b. DATE (YYYYMMDD)
The Department of Defense is notifying your office of the release of an offender who, based on available information, was convicted of a covered
sex offense under 42 U.S.C. 16911, et seq., or a crime against a victim who was a minor. The offender is subject to sex offender registration under
Federal law. For additional information, please contact POC with the facility of release who is identified below. As used in this form, state also
includes tribe or territory.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 951 (Note); 18 U.S.C. 2250; 42 U.S.C. 16911 et seq.; DoDI 1325.7; and E.O. 9397.
PRINCIPAL PURPOSE(S): To record the offender's acknowledgement of receiving sex offender registration notice and information pertaining to this
requirement, and to document an offender's expected place of residence following release.
ROUTINE USE(S): To state and local law enforcement authorities for the purpose of notification that a sex offender will be residing in a local
community and for the purpose of registering the individual as a sex offender.
DISCLOSURE: Voluntary; however, failure to provide requested information may result in the denial of your request for parole or delay your release
from confinement or military service. Required to provide this information to Federal, state and local law enforcement agencies, in accordance with
Federal law (18 U.S.C. 2250).
3. DATE OF BIRTH
4. SOCIAL SECURITY
5. DISCHARGED
6. APPELLATE REVIEW
2. NAME OF OFFENDER
(Last, First, Middle)
NUMBER
(YYYYMMDD)
(X one)
(X one)
YES
NO
YES
NO
7. CURRENT AND PRIOR CRIMINAL HISTORY OF SEXUAL OFFENSE(S)
d. VICTIM'S AGE/
b. DATE OF
a. SPECIFIC OFFENSE TITLE AND DESCRIPTION
CONVICTION
DATE OF BIRTH
c. PLACE OF CONVICTION
(5 words or more)
(YYYYMMDD)
(YYYYMMDD)
8. MAX REL DATE
9. RELEASE CONDITIONS OR RESTRICTIONS
(YYYYMMDD)
10. FACILITY OR COMMAND RELEASING OFFENDER
a. NAME OF FACILITY OR COMMAND
b. ADDRESS (Include ZIP Code)
11. CORRECTIONAL FACILITY OR COMMAND POINT OF CONTACT (POC)
c. TELEPHONE NUMBER
a. NAME (Last, First, Middle Initial)
b. ADDRESS (Include ZIP Code)
(Include
Area Code)
12. FACILITY COMMANDER OR COMMANDER RELEASING OFFENDER
a. TYPED NAME (Last, First, Middle Initial)
c. DATE SIGNED (YYYYMMDD)
b. SIGNATURE
In the event you are not the law enforcement agency with jurisdiction authority consistent with the offender's release address,
please forward these documents to the appropriate authority.
Page 1 of 3 Pages
DD FORM 2791, MAR 2013
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
NOTICE OF RELEASE/ACKNOWLEDGEMENT OF CONVICTED SEX OFFENDER
REGISTRATION REQUIREMENTS
1. TO
STATE LAW ENFORCEMENT
LOCAL LAW ENFORCEMENT
STATE SEX OFFENDER REGISTRATION OFFICIAL
U.S. MARSHALS - NATIONAL SEX OFFENDER TARGETING CENTER
a. ADDRESS (Include ZIP Code)
b. DATE (YYYYMMDD)
The Department of Defense is notifying your office of the release of an offender who, based on available information, was convicted of a covered
sex offense under 42 U.S.C. 16911, et seq., or a crime against a victim who was a minor. The offender is subject to sex offender registration under
Federal law. For additional information, please contact POC with the facility of release who is identified below. As used in this form, state also
includes tribe or territory.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 951 (Note); 18 U.S.C. 2250; 42 U.S.C. 16911 et seq.; DoDI 1325.7; and E.O. 9397.
PRINCIPAL PURPOSE(S): To record the offender's acknowledgement of receiving sex offender registration notice and information pertaining to this
requirement, and to document an offender's expected place of residence following release.
ROUTINE USE(S): To state and local law enforcement authorities for the purpose of notification that a sex offender will be residing in a local
community and for the purpose of registering the individual as a sex offender.
DISCLOSURE: Voluntary; however, failure to provide requested information may result in the denial of your request for parole or delay your release
from confinement or military service. Required to provide this information to Federal, state and local law enforcement agencies, in accordance with
Federal law (18 U.S.C. 2250).
3. DATE OF BIRTH
4. SOCIAL SECURITY
5. DISCHARGED
6. APPELLATE REVIEW
2. NAME OF OFFENDER
(Last, First, Middle)
NUMBER
(YYYYMMDD)
(X one)
(X one)
YES
NO
YES
NO
7. CURRENT AND PRIOR CRIMINAL HISTORY OF SEXUAL OFFENSE(S)
d. VICTIM'S AGE/
b. DATE OF
a. SPECIFIC OFFENSE TITLE AND DESCRIPTION
CONVICTION
DATE OF BIRTH
c. PLACE OF CONVICTION
(5 words or more)
(YYYYMMDD)
(YYYYMMDD)
8. MAX REL DATE
9. RELEASE CONDITIONS OR RESTRICTIONS
(YYYYMMDD)
10. FACILITY OR COMMAND RELEASING OFFENDER
a. NAME OF FACILITY OR COMMAND
b. ADDRESS (Include ZIP Code)
11. CORRECTIONAL FACILITY OR COMMAND POINT OF CONTACT (POC)
c. TELEPHONE NUMBER
a. NAME (Last, First, Middle Initial)
b. ADDRESS (Include ZIP Code)
(Include
Area Code)
12. FACILITY COMMANDER OR COMMANDER RELEASING OFFENDER
a. TYPED NAME (Last, First, Middle Initial)
c. DATE SIGNED (YYYYMMDD)
b. SIGNATURE
In the event you are not the law enforcement agency with jurisdiction authority consistent with the offender's release address,
please forward these documents to the appropriate authority.
Page 1 of 3 Pages
DD FORM 2791, MAR 2013
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
NOTICE OF RELEASE/ACKNOWLEDGEMENT OF CONVICTED SEX OFFENDER
REGISTRATION REQUIREMENTS
SUPPLEMENTAL LETTER
(Explain to the offender the requirements for registration in the identified jurisdiction.
Have the offender read the information carefully, then initial the block adjacent to the right of each statement.)
(Offender's Initials)
1. I,
,
,
,
,
(Full Name - Last, First, Middle)
(Grade/Rank)
(Branch)
(Social Security Number)
was convicted for the commission of (a) sexual offense(s) that (did or did not) include a sentence to
(Circle one)
confinement, and require(s) me to register as a sex offender.
2. I acknowledge that I have been informed that I will be physically released from confinement on or about
.
(YYYYMMDD)
3. I acknowledge that I have been informed that if I am retained in the armed forces, I must register as a sex
offender with both military and civilian law enforcement agencies with jurisdiction over the installation, and my
to my assigned unit.
residence upon my physical arrival on
(YYYYMMDD)
4. I certify that upon release from confinement or military service I will reside at the following address:
(Street, Apartment Number, City, State and ZIP Code)
5. I hereby acknowledge that I was informed that upon my release from confinement or military service, I am
subject to registration requirements under the Sex Offender Registration and Notification Act (SORNA) as a
sex offender within 72 hours in any state, territory, or tribal nation, in which I will reside, be employed, carry on
a vocation, or be a student.
6. I understand that if I am awaiting appellate review/administrative actions by my Service component, I am
required to register with the state and local law enforcement agencies until the appellate process is complete,
regardless of my location.
7. I understand that I must also register at least 21 days prior to any international travel.
8. I understand that I must contact the office that follows, to ensure that sex offender registration requirements
are met:
(Organization, Address (Include ZIP Code), and Telephone Number)
9. I understand that should the office listed in block 8 not be the correct point of registry for the jurisdictions in
which I plan to reside, be employed, or go to school, I will seek out and register at all appropriate offices.
10. I acknowledge I have been informed that the sex offender registry of the jurisdiction in which I will reside upon
release from confinement or military service is being provided written notice about the offense(s) for which I
was convicted, that I am subject to a registration requirement as a sex offender, and the date I was released
from confinement or military service.
11. I acknowledge I have been informed that every change in my local address must be reported in the manner
provided by state or tribal law.
12. I acknowledge I have been informed that if I move to another state, I must report the change of address to
the responsible agency in the state I am leaving, and comply with the registration requirements in the new
state of residence.
13. I acknowledge I have been advised and understand that if I do not register and/or change or update such
information as required by a relevant state, tribal or territorial sex offender registration program, my failure to
comply with these requirements could result in such penalties as revocation of parole/MSR or prosecution
under Federal law (18 U.S.C. 2250), punishable by up to 10 years imprisonment.
14. Signed on this
day of
,
.
a. WITNESS:
b. OFFENDER:
(Signature)
(Signature)
(Print Full Name - Last, First, Middle Initial)
(Print Full Name - Last, First, Middle Initial)
Page 2 of 3 Pages
DD FORM 2791, MAR 2013
INSTRUCTIONS FOR COMPLETING DD FORM 2791
THE AGENCY THIS DD FORM 2791 IS BEING
CORRECTIONAL FACILITY OR COMMAND POINT OF
FORWARDED TO
CONTACT (POC)
Block 1. Identify the type of law enforcement agency
Block 11.a. Enter last name, first name, and middle initial of
notification is being sent.
facility POC.
Block 1.a. List the agency address, to include city, state
Block 11.b. Enter address of facility POC, to include ZIP
and ZIP Code.
Code.
Block 1.b. Enter the date the form is being filled out
Block 11.c. Enter the telephone number of facility POC,
(YYYYMMDD - Year/ Month/Day).
including area code.
NOTE: The Privacy Act Statement should be read by
FACILITY COMMANDER OR COMMANDER RELEASING
all applicable offenders.
OFFENDER
Block 12.a. Enter last name, first name, and middle initial of
OFFENDER'S PERSONALLY IDENTIFIABLE
correctional facility commander or the commander releasing
INFORMATION
the offender, including rank or title.
Block 2. Enter the applicable offender's last name, first
Block 12.b. Facility commander's signature required or the
name and middle name.
commander releasing the offender.
Block 3. Enter the applicable offender's date of birth
Block 12.c. Enter the date the form was signed (YYYYMMDD
(YYYYMMDD - Year/Month/Day).
- Year/Month/ Day).
Block 4. Enter the applicable offender's complete Social
Security number.
PAGE 2, SUPPLEMENTAL LETTER
DISCHARGED
NOTE 1: Have offender read the information below
Block 5. Mark (X) the appropriate block (Yes or No) for the
carefully, then initial the block adjacent to the right of
offender's affiliation with the military service.
each statement.
APPELLATE REVIEW
Block 1. Enter the offender's full name, grade/rank (if
Block 6. Mark (X) the appropriate block (Yes or No) if
applicable), branch of Service, Social Security number, and
offender is awaiting or undergoing the appellate review
select the appropriate response to indicate if the conviction(s)
process.
included a sentence to confinement.
CURRENT AND PRIOR HISTORY OF SEXUAL
Block 2. If applicable, annotate the date the offender is
OFFENSE(S)
physically being released from the correctional facility.
Block 7.a. List all current and prior criminal history of
sexual offenses (use brevity and conciseness in this limited
Block 3. If applicable, annotate the date the offender will
space).
report to his/her unit of assignment.
Block 7.b. Enter the date of conviction (YYYYMMDD -
Year/Month/Day).
Block 4. Enter the complete residence address including the
Block 7.c. Enter place of conviction (installation or city and
city, state and ZIP Code.
state).
Block 7.d. Annotate the age and date of birth
Block 8. Enter the name of the law enforcement agency and
(YYYYMMDD - Year/Month/Day) of the victim(s). It is
the complete address (including city, state and ZIP Code) and
important that the age of the victim(s) associated with the
telephone number (including the area code and extension, if
offender are annotated of not just minors, as the definition
applicable) where the offender is required to report for
of a minor may vary from jurisdiction to jurisdiction. If this
registration upon release from confinement or the Service
information is not in the court martial documents, ask the
Component.
prisoner.
Block 14. Enter the date the offender signed the
MAX REL DATE
Supplemental Letter. The witness and the offender sign the
Block 8. Enter offender's maximum release date from
letter and legibly print their names on the appropriate line
confinement (if applicable).
below their signatures. If an offender refuses to sign the
letter, write "OFFENDER REFUSED TO SIGN" on the
RELEASE CONDITIONS OR RESTRICTIONS
offender's signature line, notify the Commander, and process
Block 9. Annotate reason for release (i.e., expiration of
the form unless instructed otherwise.
sentence, parole, or MSR).
FACILITY OR COMMAND RELEASING OFFENDER
Block 10.a. Enter the complete correctional facility name.
Block 10.b. Enter the complete address of the correctional
facility location that the offender is being released from,
including city, state and ZIP Code.
Page 3 of 3 Pages
DD FORM 2791, MAR 2013
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