HOUSE_OVERSIGHT_021632

® * si Vv, 12-19-06) Accomplishment Report Date Prepared 9/0 ‘4 b6é quad supervisor approval (Accomplishment must be reported and loaded into Date Loaded t Os

please initial) ISRAA within 30 days from date of accomplishment)

Date Loader’s Initial:

Investigative Assistance or Technique Used Accomplishment involves:

(check all that apply) File Number 1. Used, but did not help 3. Helped, substantially \3/€-MIM-168 CZ] 2. Helped, minimally 4, Absolutely essential

For Sub. Invest. Assist. by other FO(s) indicate A, B, C, D for corresponding FO Rate FO \AT Rate FO

IAT 7 Lab. Field Sup

Aircraft Asst, | | Pen Registers

L [Photo Gover_| | [Povyerepn | |

Rate FO AT Rate FO [AT

[| Juco-nasoa] I rsa |

Bankruptcy Fraud Computer Fraud/Abuse Corruption of Public Official Money Laundering Sub Invest Asst by FO(s)

Stat Agent Name

Computer

|| Consen Mon. | |

DOOODOoO

J. Civil Rico Matters Date: Also complete “Section G”

Other Civit Matters Date:

CXSICTD infraGard/CyD OFCICID

Swat Team Tech. AgiEquip. Phone Toll Ree

4 Eng. Tape Ex.

J [evs Purchos|

ee ee

hee | F, Conviction

A. Complaint / information/ indictment (Federal [Jtocal [] International [Federal [Local [7] International Conviction Date:

Complaint Date:

ELSUR/T. Ill

Check if Civil Rico Complaint O Subject Description Code *“—)" gant ; ° Judicial Outcome____.§__ OK Information Date: For 6F, G, H-Include Agency Code Amount $ Indictment Date: = Palony , OF 5 MISHENEAGE Suspension: Years Months. Plea or Trial

B. Locate / Arrest State: Judicial District:

[J Federal [Locat [J International Subject Priority; OA (1B [1c

K. Administrative Sanction Date: Subject Description Code © Type: Length:

G, U.S. Code Violation

Required for sections A, B, F and J Suspension (Permanent Locate Date: (Federal Only) : Debarment or Arrest Date: Title Section # Counts Injunction Year. Months

(7) Subject Resisted Arrest (1) Subject Arrested was Armed

L, Asset Seizure Date: Asset Forfeiture Date: CATS # Mandatory.__ EE Circle below one of the three asset forfeiture:

Admin, Civil Judicial, or Criminal

C. Summons Date: (} Federal ([] Local

D. Recovery / Restitution / PELP X (Federal [Local [7 International Recovery Date:

Code * vy Amount $_

Code * v Amount $

Restitution Date:

Do nat indicate $ value in Section D

H. Sentence Date:

Sentence Type: * M. Acquittal/ Dismissal/ Pretrial Diversion

(Circle one) Date:

In Jail: Years Months_____

Suspended: Years____._. Months. N. Drug Seizures “Date:

(Court Ordered ([] Pretrial Diversion Probation: Years Months_____. Drug Code © Code * Y Amount $ Fines: $ aa Code FELF Date: @ Do not indicate $ in Section D Code*__ vy) =Amount $ 1. Disruption/Dismantlement: “

E. Hostages(s) Released Date:

Disruption Date:

Released by: [[] Terrorist ([} Other

0, Child Victim Information Child located / identified Date: 0fzofroy

PRuving (1 Deceased

Dismantlement Date:

Number of Hostages: Completion of FD-515a Side 2 Mandatory

b6 b7C

P, Subject Information - Required for all blocks excluding block D (Recovery/PELP), blocks &, |, Land N

| Race* | Sex | DateofBith Social Security No. {if available) PS Ga | OO

Subjact related to an LEN, ASian Organized Crime (ACC), ttallan Organized Cnme (IOC), Russian/Eastern European, Caribbean, or Nigerian Organized Crime Group - Complete FD-515a, Side 1 Blocks A-E mandatory, F-H as appropriate,

oO Subject related to an OC/Drug organization, a VCMO Program National Gang Stralegy targel group, or a VCMO Program National Priority Initiative targel group - Complate FO-515a, Side 1 Blocks A-C only. ‘

x Additional information may be added by attaching another form or a plain sheet of paper for additional entries. selal NG: GLFO-aIe

~ Sad atlas SHTSVEIES Side, Pp

¥ Requires that an explanation be attached and loaded into ISRAA for recovery over $1 m and PELP over $5 m, disruption, dismantlement, and drug seizures.

3/E-MH - (08062 - 20g

HOUSE_OVERSIGHT_021632