Prob 11G - NCW (Rev 12/12) AUTHORIZATION TO RELEASE INFORMATION PRIVATE PERSON OR ORGANIZATION TO PROBATION OFFICER TO WHOM IT MAY CONCERN: (NAME) (SSN) (DOB) I, the undersigned, hereby authorize the United States Probation Office for the Western District of North Carolina or its authorized representative(s) or employee(s), bearing release or copy hereof, to obtain any information in your files pertaining to any of the following: EMPLOYMENT AND SOCIAL SECURITY ADMINISTRATION RECORDS (including but not limited to the Detailed Earnings History) under the Freedom of Information Act, EDUCATION RECORDS (including but not limited to academic achievement, attendance, athletic, personal history, and disciplinary records), MEDICAL RECORDS, PSYCHOLOGICAL AND PSYCHIATRIC RECORDS (including any alcohol and substance abuse diagnosis, treatment and after-care), CREDIT BUREAU REPORTS, MILITARY RECORDS, and JUVENILE COURT RECORDS. I hereby direct you to release such information. This release is executed with full knowledge and understanding that the information is for the United States Probation Office's official use. I hereby release you, as custodian of such records, from any and all liability for damages of whatever kind which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request for information or any other attempt to comply with it. Regarding protected health information, I understand that this authorization is valid until my release from supervision, at which time this authorization to use or disclose this information expires. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Regarding protected health information, I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the program's privacy contact at: (Name and Address of Program) Regarding protected health information, I understand that if I revoke this authorization to release confidential information, I will thereby revoke my authorization to further disclosure of such information. I also understand that revoking this authorization before I satisfy the condition of my supervision that requires me to participate in the program will be reported to the court. My revocation of authorization under such circumstances could be considered a violation of a condition of my post-conviction supervision. The information hereby obtained by the aforementioned probation office is to be used only for the purpose of presentence investigations and reports, and, if applicable, for supervision. (Authorizing Signature) (Name - Printed or Typed) (Date) (USPO/Witness Signature) (Name - Printed or Typed) This release and request form is approved for official use by the United States Probation Officer by authority of the United States District Court for the Western District of North Carolina. American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT NORTH CAROLINA WESTERN PROBATION OFFICE PERSONAL AND FAMILY HISTORY PLEASE COMPLETE THE REQUESTED INFORMATION BELOW: (Attach Additional Pages if Necessary) The United States Probation Office ("USPO") requests this information as part of its duty to undertake a presentence investigation pursuant to Federal Rule of Criminal Procedure 32(c). The USPO may include the information provided in the defendant's presentence report, but it will not use the information for any other purpose. The presentence report will be disclosed to defense counsel, counsel for the U.S. government, and the U.S. District Court responsible for sentencing, and it may be disclosed to the U.S. Parole Commission and the Federal Bureau of Prisons. Subject to those exceptions, the USPO will not disclose the information provided to any other entity. Defendant's Name:__________________________________ WDNC Docket No:__________________________________ Failure to disclose requested information may adversely affect your defendant in sentencing designation and Bureau of Prisons programming (mental health, substance abuse, education, etc.). A presentence report cannot be changed once sentencing has occurred. True, Complete/Full Name: Other Names Used by Defendant: Include maiden or married names, alternate names or nicknames. American LegalNet, Inc. www.FormsWorkFlow.com 2 NC Driver's License Number: ______________________________ Have you been issued a driver's license number in any other state? If so, where? State Driver's License No. Date of Birth: _______________________________________ Place of Birth: City County State U.S. Citizen Citizen of Another Country: __________________ (name of country) What is your status in the United States? Legal Alien Naturalized Citizen Permanent Resident Alien Other: ______________________________________________________________________ If not a United States citizen, when did you first enter the United States? _________________ List Scars, Marks and Tattoos: American LegalNet, Inc. www.FormsWorkFlow.com 3 Defendant's Address: List city, county and state where you've lived from birth to present. Date You Lived at this Residence Address American LegalNet, Inc. www.FormsWorkFlow.com 4 Parents' Names: Name of Biological Mother Address DOB Mother's Telephone No. and/or Email Address Mother's Occupation and Current Health Status Name of Biological Father Address DOB Father's Telephone No. and/or Email Address Father's Occupation and Current Health Status Name of any other individual(s) who was, or is today, an important person in your life: Step-parent, grandparent, foster parent, guardian, etc. Include age and address of this individual and your current relationship. Name Relationship Age Address Keep in Contact?/ How Often? American LegalNet, Inc. www.FormsWorkFlow.com 5 Brother(s) and Sister(s) Name(s): Include age and address (city or county, and state) Name Address DOB or Age Spouse(s) Name(s): List the name of your current spouse, if applicable, and include the names of any former spouses. List the place and date (approximate if date unknown) of the marriage(s). Name Address DOB Place & Dates of Marriage Children's Names: List the names of any children you may have (include their age and address and other parent's name and frequency of contact with children; if applicable; include the amount of financial support you provide. Name and Age Add