DD Form 2716-1 Certificate of Supervised Release

DD Form 2716-1 - also known as the "Certificate Of Supervised Release" - is a Military form issued and used by the United States Department of Defense.

The form - often incorrectly referred to as the DA form 2716-1 - was last revised on March 1, 2013. Download an up-to-date fillable DD Form 2716-1 down below in PDF-format or find it on the Department of Defense documentation website.

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DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
(Last, First, Middle)
(Social Security Number)
(Date - YYYYMMDD)
being eligible for supervised release under the terms and conditions prescribed by the prisoner's respective branch of service, will be
released on community supervision from the
Supervisee's Facility Address (Facility Name/State/ZIP Code)
provided that the supervised release plan for residence, employment, and U.S. Probation Officer has been completed and the
supervisee complies with the provisions and conditions prescribed in this Certificate of Supervised Release and further provided that
all conditions set forth by the respective branch of service and facility commander are met and the supervisee continues to perform
satisfactorily until release from supervision.
The term of supervision hereby granted will become effective on
and will expire on
(Date - YYYYMMDD)
(MaxRel Date - YYYYMMDD)
unless sooner suspended or revoked for violation of its conditions or otherwise terminated by competent authority.
Signed
(Chair, Parole and Clemency Board)
ENDORSEMENT
The above named individual was released from confinement and placed on
(Mandatory Supervised Release or Parole)
the
day of
,
.
Dated
Signed
(YYYYMMDD)
(Commander of Correctional Facility)
DISTRIBUTION
File completed original in the prisoner/supervisee's Correctional Treatment Folder (facility). Provide a copy to the supervisee; send
one copy to the supervisee's probation officer; and one copy to the supervisee's Clemency and Parole Board.
DD FORM 2716-1, MAR 2013
Page 1 of 4 Pages
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
(Last, First, Middle)
(Social Security Number)
(Date - YYYYMMDD)
being eligible for supervised release under the terms and conditions prescribed by the prisoner's respective branch of service, will be
released on community supervision from the
Supervisee's Facility Address (Facility Name/State/ZIP Code)
provided that the supervised release plan for residence, employment, and U.S. Probation Officer has been completed and the
supervisee complies with the provisions and conditions prescribed in this Certificate of Supervised Release and further provided that
all conditions set forth by the respective branch of service and facility commander are met and the supervisee continues to perform
satisfactorily until release from supervision.
The term of supervision hereby granted will become effective on
and will expire on
(Date - YYYYMMDD)
(MaxRel Date - YYYYMMDD)
unless sooner suspended or revoked for violation of its conditions or otherwise terminated by competent authority.
Signed
(Chair, Parole and Clemency Board)
ENDORSEMENT
The above named individual was released from confinement and placed on
(Mandatory Supervised Release or Parole)
the
day of
,
.
Dated
Signed
(YYYYMMDD)
(Commander of Correctional Facility)
DISTRIBUTION
File completed original in the prisoner/supervisee's Correctional Treatment Folder (facility). Provide a copy to the supervisee; send
one copy to the supervisee's probation officer; and one copy to the supervisee's Clemency and Parole Board.
DD FORM 2716-1, MAR 2013
Page 1 of 4 Pages
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional X
DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
1.a. PROBATION/PAROLE OFFICER NAME
b. TELEPHONE NUMBER
(Last, First, Middle)
(Include area code)
c. AGENCY ADDRESS
d. CITY
e. STATE
f. ZIP CODE
2. SUPERVISED RELEASE DESTINATION (Limitation of travel is designated by Parole Officer)
3. CONDITIONS
This Certificate of Supervised Release shall become operative when the prisoner has been notified in writing of the following
conditions:
a. When released, the supervisee will go without delay to the supervision destination as specified above.
b. Within three working days of release, supervisees will report in person to their probation officer, unless directed otherwise by their
probation officer. They will follow their probation officer's reporting instructions and report as directed. After reporting, the supervisee
will complete the Notification of Arrival letter and forward it to
Supervisee's Facility Address (Facility Name/State/ZIP Code)
c. Supervisees will remain within the limits prescribed by their probation officer, and, if they have justifiable cause to leave these
limits temporarily, they will first obtain permission from their probation officer.
d. Supervisees will not change the residence and employment approved in their supervised release plan without first receiving
permission from their probation officer. In the event their residence or employment is involuntarily terminated, they will report these
events to their probation officer within one working day of being notified of such termination.
e. Failure to maintain contact with their probation officer constitutes absconding.
f. Supervisees will promptly and truthfully answer all inquiries directed to them by their respective branch of service, their
commander, their probation officer, or other persons acting in an official capacity.
g. Supervisees will not associate with persons of bad or questionable reputation, nor enter or frequent places where controlled
substances are sold, used, distributed or administered.
h. Supervisees will in all respects conduct themselves in an honorable manner, work diligently at a lawful occupation, support those
dependent on them, meet other family and financial responsibilities to the best of their ability, and avoid unnecessary or excessive
debt.
i. Supervisees will live and remain at liberty without violating the law. Supervisees shall consider themselves convicted felons and
understand that all laws regulating convicted felons may apply; should they have questions they will seek guidance from their
probation officer or Service Clemency and Parole Board.
j. Supervisees will refrain from the excessive use of alcohol and will not purchase, possess, use, distribute or administer any
narcotic or other controlled substance or any paraphernalia related to such substances, except as prescribed by a physician.
k. Supervisees will notify their probation officer within 24 hours of being arrested, detained, or questioned by a law enforcement
officer.
l. Supervisees will not enter into any agreement to act as an informer or special agent of a law enforcement agency without the
permission of their Service Clemency and Parole Board.
m. Supervisees also understand and agree that if they violate any of the conditions of their supervised release, they may be
apprehended or returned to military control, and be held liable to serve the remainder of their sentence to confinement and forfeit
their time served on supervised release, as well as previously earned good conduct time and other abatements.
n. If accepting parole, supervisees waive all good conduct time and abatement earned up to their release date (not applicable to
Mandatory Supervised Release).
o. Supervisees will not possess a firearm, ammunition, or other dangerous weapon.
p. Supervisees will comply with additional conditions of their Supervised Release.
(Listed on subsequent pages)
DD FORM 2716-1, MAR 2013
Page 2 of 4 Pages
DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
SUPERVISEE NAME (Last, First, Middle Initial)
SOCIAL SECURITY NUMBER
4. ADDITIONAL CONDITIONS AND STATEMENT OF UNDERSTANDING
I understand that release on supervision is contingent upon full disclosure of all of my conditions of release to my supervising U.S.
probation officer if they do not yet have a copy, and complying with all instructions of my supervising U.S. probation officer, and:
(NOTE: Clemency and Parole Boards will insert additional conditions of release.)
I thoroughly understand the foregoing additional conditions and solemnly promise to abide by them. I also understand that if I violate
any of the additional conditions, such a violation will be considered a violation of the basic supervision agreement.
(Signature)
(Date - YYYYMMDD
(SSN)
(Witness Signature)
(Typed Name/Grade)
(Date - YYYYMMDD)
DD FORM 2716-1, MAR 2013
Page 3 of 4 Pages
DEPARTMENT OF DEFENSE
CERTIFICATE OF SUPERVISED RELEASE
5. APPLICABLE ONLY IF THE APPELLATE REVIEW OF THE COURTS-MARTIAL SENTENCE IS NOT COMPLETE
a. I voluntarily apply for excess leave without pay and allowances to become effective in the event of expiration of my term to
confinement prior to completion of appellate action on my court-martial sentence. I understand that for pay purposes,
I am in excess leave status during the period of supervised release, except to the extent I may be entitled to pay and allowances for
accrued leave which was not forfeited by my court-martial sentence.
b. I agree not to wear the military uniform following release on supervision.
c. I understand that in the event my court-martial sentence is set aside by appellate review, I may be ordered to return to an active
duty status.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C.
952, P.L. 90-377, and E.O. 9397.
PRINCIPAL PURPOSE(S): To certify an offender for Supervised Release from confinement, notify the individual of the Conditions
of Supervised Release, and record the individual's release from confinement and placement on Supervised Release.
ROUTINE USE(S): To the Department of Justice, in instances where the prisoner is incarcerated in a Federal Bureau of Prisons
facility, and to inform U.S. Probation Officers and the Administrative Office of the U.S. Courts of the Conditions of Supervised
Release.
DISCLOSURE: Voluntary; however, failure to provide the requested information as required in block 6a. may result in denial or
revocation of Supervised Release.
6. PRISONER CERTIFICATION.
I have been notified of, read and understand the foregoing conditions. I
accept
do not accept Supervised Release.
a. PRISONER SIGNATURE
b. DATE (YYYYMMDD)
7. WITNESS
a. NAME
, GRADE, TITLE
b. SIGNATURE
c. DATE (YYYYMMDD)
(Last, First, Middle Initial)
DD FORM 2716-1, MAR 2013
Page 4 of 4 Pages

Download DD Form 2716-1 Certificate of Supervised Release

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