BP-A0629 A R
VISITOR INFORMATION U.S. DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS
Re: (Inmate’s Name and Register No.)
I am requesting that you be included among my approved visitors. In order to establish your suitability as a visitor, it may be necessary for institution officials to send an inquiry to an appropriate law enforcement or crime information agency to ascertain whether or not placing you on my visiting list would present a management problem for the institution, or have other possible adverse effects. The information obtained will be used to determine your acceptability as a visitor. The Bureau of Prisons’ authority to request background information on proposed visitors is contained in Title 18 U.S.C. § 4042. In order for you to be considered for the visiting privilege with me, it will be necessary for you to fill out the questionnaire and release form below and return it to the following address: (Institution address). You are not required to supply the information requested. However, if you do not furnish the information, the processing of your request will be suspended, and you will receive no further consideration. If you furnish only part of the information required, the processing of your request may be significantly delayed. If the information withheld is found to be essential to the processing of your request, you will be informed, and your request will receive no further consideration unless you supply the missing information. Although no penalties are authorized if you do not supply the information requested, failure to supply such information could result in your not being considered for admittance as a visitor. The criminal penalty for making false statements is a fine of not more than $250,000 or imprisonment for not more than five years or both (See 18 U.S.C. § 1001). Sincerely, 1. Legal Name 4. Telephone Number (Including Area Code) 6. Are you a U.S. Citizen? Yes No 2. Date of Birth 5. Race and Sex of Visitor 3. Address (Including Zip Code)
6a. If yes, provide Social Security No: 6b. If no, provide Alien Registration No: 6c. Provide Passport No:
7. Relationship to above-named inmate
8. Do you desire to visit him/her? Yes No Yes No
9. Did you know this person prior to his/her current incarceration?
10. If the answer to #9 is yes, indicate the length of time you have known this person and where the relationship developed. 11. Have you ever been convicted of a crime? conviction/s: If so, state the number, date, place, and nature of the
12. Are you currently on probation, parole, or any other type of supervision? If so, state the name of your supervising probation/parole officer and the address and telephone no. where he/she can be contacted:
13. Do you correspond or visit with other inmates? 14. Driver’s License No. and State of Issuance
If so, indicate the individual(s) and their location(s):
AUTHORIZATION TO RELEASE INFORMATION I hereby authorize release to the Warden of: ________________________ any record of criminal offenses for which I (Institution, Location) have been arrested and convicted, and any information related to those convictions. Signature for Authorization to Release Information (Sign and Print Name)Parent or Guardia
(If applicant is under 18 years of age, signature of parent or guardian indicates consent of minor to visit inmate). If additional space is required, you may use the back of this form. To be filed in Inmate Central File, FOI Section 2 PDF Prescribed by P5267 Replaces BP-A629 of Sep 00
FILE IN SECTION 3 UNLESS APPROPRIATE FOR PRIVACY FOLDER
INFORMACIÓN DE VISITANTE CDFRM AGENCIA FEDERAL DE PRISIONES
DEPARTAMENTO DE JUSTICIA DE EE.UU.
**This template is provided to assist Spanish-speaking inmates who are not fluent in English to complete the corresponding Bureau form. It is a template only for instructional purposes, and should not be...
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