AO 245I (Rev. 12/03) Judgment in a Criminal Case for a Petty Offense Sheet 1 UNITED STATES DISTRICT COURT District of UNITED STATES OF AMERICA V. JUDGMENT IN A CRIMINAL CASE (For a Petty Offense) CASE NUMBER: USM NUMBER: Defendant’s Attorney THE DEFENDANT: G THE DEFENDANT pleaded G guilty G nolo contendere to count(s) G THE DEFENDANT was found guilty on count(s) The defendant is adjudicated guilty of these offenses: Title & Section Nature of Offense Offense Ended The defendant is sentenced as provided in pages 2 through Count of this judgment. G THE DEFENDANT was found not guilty on count(s) G Count(s) G is G are dismissed on the motion of the United States. It is ordered that the defendant must notify the United States attorney for this district within 30 days of any change of name, residence, or mailing address until all fines, restitution, costs, and special assessments imposed by this judgment are fully paid. If ordered to pay restitution, the defendant must notify the court and United States attorney of material changes in economic circumstances. Defendant’s Soc. Sec. No.: Date of Imposition of Judgment Defendant’s Date of Birth: Signature of Judge Defendant’s Residence Address: Name of Judge Title of Judge Date Defendant’s Mailing Address: American LegalNet, Inc. www.FormsWorkflow.com (Rev. 12/03) Judgment in a Criminal Case for a Petty Offense Sheet 2 — Imprisonment AO 245I Judgment — Page DEFENDANT: CASE NUMBER: of IMPRISONMENT The defendant is hereby committed to the custody of the United States Bureau of Prisons to be imprisoned for a total term of : G The court makes the following recommendations to the Bureau of Prisons: G The defendant is remanded to the custody of the United States Marshal. G The defendant shall surrender to the United States Marshal for this district: G G G at G as notified by the United States Marshal. a.m. G p.m. on . The defendant shall surrender for service of sentence at the institution designated by the Bureau of Prisons: G before 2 p.m. on G as notified by the United States Marshal. G as notified by the Probation or Pretrial Services Office. . RETURN I have executed this judgment as follows: Defendant delivered on at to with a certified copy of this judgment. UNITED STATES MARSHAL By DEPUTY UNITED STATES MARSHAL American LegalNet, Inc. www.FormsWorkflow.com (Rev. 12/03) Judgment in a Criminal Case for a Petty Offense Sheet 3 — Criminal Monetary Penalties AO 245I Judgment — Page DEFENDANT: CASE NUMBER: of CRIMINAL MONETARY PENALTIES The defendant must pay the total criminal monetary penalties under the schedule of payments on Sheet 4. Assessment TOTALS Fine $ Restitution $ $ G The determination of restitution is deferred until after such determination. G The defendant must make restitution (including community restitution) to the following payees in the amount listed below. . An Amended Judgment in a Criminal Case (AO 245C) will be entered If the defendant makes a partial payment, each payee shall receive an approximately proportioned payment, unless specified otherwise in the priority order or percentage payment column below. However, pursuant to 18 U.S.C. § 3664(i), all nonfederal victims must be paid in full prior to the United States receiving payment. Name of Payee Total Loss* Restitution Ordered TOTALS $ $ Priority or Percentage G Restitution amount ordered pursuant to plea agreement $ G The defendant must pay interest on restitution or a fine of more than $2,500, unless the fine or restitution is paid in full before the fifteenth day after the date of the judgment, pursuant to 18 U.S.C. § 3612(f). All of the payment options on Sheet 4 may be subject to penalties for delinquency and default, pursuant to 18 U.S.C. § 3612(g). G The court determined that the defendant does not have the ability to pay interest, and it is ordered that: G the interest requirement is waived for the G the interest requirement for the G fine G fine G G restitution. restitution is modified as follows: * Findings for the total amount of losses are required under Chapters 109A, 110, 110A, and 113A of Title 18 for offenses committed on or after September 13, 1994, but before April 23, 1996. American LegalNet, Inc. www.FormsWorkflow.com AO 245I (Rev. 12/03) Judgment in a Criminal Case for a Petty Offense Sheet 3A — Criminal Monetary Penalties Judgment — Page DEFENDANT: CASE NUMBER: of ADDITIONAL RESTITUTION PAYEES Name of Payee Total Loss* Restitution Ordered Priority or Percentage * Findings for the total amount of losses are required by Chapters 109A, 110, 110A, and 113A of Title 18 for offenses committed on or after September 13, 1994, but before April 23, 1996. American LegalNet, Inc. www.FormsWorkflow.com AO 245I (Rev. 12/03) Judgment in a Criminal Case for a Petty Offense Sheet 4 — Schedule of Payments Judgment — Page DEFENDANT: CASE NUMBER: of SCHEDULE OF PAYMENTS Having assessed the defendant’s ability to pay, payment of the total criminal monetary penalties are due as follows: A G Lump sum payment of $ G G not later than in accordance with due immediately, balance due G C, G D, G , or E, or G G C, F below); or B G Payment to begin immediately (may be combined with G D, or G F below); or C G Payment in equal (e.g., weekly, monthly, quarterly) installments of $ over a period of (e.g., months or years), to commence (e.g., 30 or 60 days) after the date of this judgment; or D G Payment in equal (e.g., weekly, monthly, quarterly) installments of $ over a period of (e.g., months or years), to commence (e.g., 30 or 60 days) after release from imprisonment to a term of supervision; or E G Payment during the term of probation will commence within (e.g., 30 or 60 days) after release from imprisonment. The court will set the payment plan based on an assessment of the defendant’s ability to pay at that time; or F G Special instructions regarding the payment of criminal monetary penalties: Unless the court has expressly ordered otherwise, if this judgment imposes imprisonment, payment of criminal monetary penalties is be due during the period of imprisonment. All criminal monetary penalties, except those payments made through the Federal Bureau of Prisons’ Inmate Financial Responsibility Program, are made to the clerk of the court. The defendant shall receive credit for all payments previously made toward any criminal monetary penalties imposed. G Joint and Several Defendant and Co-Defendant Names, Case Numbers (including defendant number), Total Amount, Joint and Several Amount, and corresponding payee, if appropriate. G The defendant shall pay the cost of prosecution. G The defendant shall pay the following court cost(s): G The defendant shall forfeit the defendant’s interest in the following property to the United States: Payments shall be applied in the following order: (1) assessment, (2) restitution principal, (3) restitution interest, (4) fine principal, (5) fine interest, (6) community restitution, (7) penalties, and (8) costs, including cost of prosecution and court costs. American LegalNet, Inc. www.FormsWorkflow.com AO 245I (Rev. 12/03) Judgment in a Criminal Case for a Petty Offense Sheet 5 — Probation Judgment—Page DEFENDANT: CASE NUMBER: of PROBATION The defendant is hereby sentenced to probation for a term of: The defendant shall not commit another federal, state, or local crime. The defendant shall not unlawfully possess a controlled substance. The defendant shall refrain from any unlawful use of a controlled substance. The defendant shall submit to one drug test within 15 days of placement on probation and at least two periodic drug tests thereafter as determined by the court. G The above drug testing condition is suspended, based on the court’s determination that the defendant poses a low risk of future substance abuse. (Check, if applicable.) G G G The defendant shall not possess a firearm, ammunition, destructive device, or any other dangerous weapon. (Check, if applicable.) G The defendant shall participate in an approved program for domestic violence. (Check, if applicable.) The defendant shall cooperate in the collection of DNA as directed by the probation officer. (Check, if applicable.) The defendant shall register with the state sex offender registration agency in the state where the defendant resides, works, or is a student, as directed by the probation officer. (Check, if applicable.) If this judgment imposes restitution or a fine, it is a condition of probation that the defendant pay in accordance with the Schedule of Payments sheet of this judgment. The defendant must comply with the standard conditions that have been adopted by this court as well as with any additional conditions on the attached page. STANDARD CONDITIONS OF SUPERVISION 1) the defendant shall not leave the judicial district without the permission of the court or probation officer; 2) the defendant shall report to the probation officer and shall submit a truthful and complete written report within the first five days of each month; 3) the defendant shall answer truthfully all inquiries by the probation officer and follow the instructions of the probation officer; 4) the defendant shall support his or her dependents and meet other family responsibilities; 5) the defendant shall work regularly at a lawful occupation, unless excused by the probation officer for schooling, training, or other acceptable reasons; 6) the defendant shall notify the probation officer at least ten days prior to any change in residence or employment; 7) the defendant shall refrain from excessive use of alcohol and shall not purchase, possess, use, distribute, or administer any controlled substance or any paraphernalia related to any controlled substances, except as prescribed by a physician; 8) the defendant shall not frequent places where controlled substances are illegally sold, used, distributed, or administered; 9) the defendant shall not associate with any persons engaged in criminal activity and shall not associate with any person convicted of a felony, unless granted permission to do so by the probation officer; 10) the defendant shall permit a probation officer to visit him or her at any time at home or elsewhere and shall permit confiscation of any contraband observed in plain view of the probation officer; 11) the defendant shall notify the probation officer within seventy-two hours of being arrested or questioned by a law enforcement officer; 12) the defendant shall not enter into any agreement to act as an informer or a special agent of a law enforcement agency without the permission of the court; and 13) as directed by the probation officer, the defendant shall notify third parties of risks that may be occasioned by the defendant’s criminal record, personal history, or characteristics and shall permit the probation officer to make such notifications and confirm the defendant’s compliance with such notification requirement. American LegalNet, Inc. www.FormsWorkflow.com AO 245I (Rev. 12/03) Judgment in a Criminal Case for a Petty Offense Sheet 5A — Probation Supervision DEFENDANT: CASE NUMBER: Judgment — Page of SPECIAL CONDITIONS OF SUPERVISION American LegalNet, Inc. www.FormsWorkflow.com