Page 1 of 70
LA1% LNMRCENIE\ I MASI FIVE
I N. l)rpartment of Justice
oiled States .%larshals Sin ice
Personal History of Defendant
liken i to Federal custody by the following:
Street Arrest (not from a correctional detention facility )
O Custodial Arn:si (from a correctional detention facility)
K
estrrit 1 sed (Must pros ide copy of yyrit) /4141:'-'r
Prior Federal Arrest or Safi:keeper - Register u:
O lyarckecper Location:
Blind( \PIM \I INISIlt \ I \ I lit\
Last Name:
7-
Sex:
r
Transgendcr
flair: 6
City of Birth:
et
1:10 N:
Resident Address/City/State/ZIP: 9
ex*
home Phone:
Cell Phone:
1
First Name:
Eyes: S/oct
Statett'ountry of Birth:
State Inn:
rivy9
Middle Name:
lull RI ( v.!
Agent Last Name
Agent Phone N:
I.ocation/Facility of Arrest:
Court Docket 0:
Al SA(s) Assigned:
gencv 0121:
01 I I NNI
I NCR' Code
Charge Description SitlArr/C.,11,/j
t.st. 7/
Known Detainers/%Varranis: eft' O •i• - Agency:
( \I 'Inv. \\I) \ii 1)11
tAiusi pan lilt a rap) of am ;Mann n)
Lung Term Medical Conditions
bean problem.. Jabot.. mama. Where uloth. I II V. AIDS. Seim ItIK. met
O
Psychiatric/Emotionally Disturbed ir.s.. mental health f011talli...ultid
Al. etc.1:
Injuries/Medical Ailments/Post-Op Recovery:
D
Do the shove conditions empire:
Medical attention?
N O 1'
Medication?
\
K 1'
Medical clearance by a licensed physician: Nit] \
K 1'
Is Defendant under the influence of drugs or alcohol: ism K 1'
Languages - F:nglivh:
K N .16❑
i.imited
Other Language:
N
• i.ist:
Security Cautions:
C rrent or former military
t or former public official
I gild,: liw diplomatic immunity
Ihreal to witness (Describe Moo/
0 Current or former I.I. corrections
K Assault on LI: corrections
K Leadership mk
O Ci /Describe below,
El Current or runner intelligence
K SAM subjr:ct or candidate
K Separation weds ilktecrine Mott I
K Other !Describe helm.;
Title/Code
TES
Page I or 3
Form USM-312
Rev 11/17
EFTA00040006