OPROB 1 (Rev. 4/01) UNITED STATES DISTRICT COURT Federal Prob ation System WORKSHEET FOR PRESENTENCE REPORT (See Publication 107 for Instruction) 1. FACESHEET DATA Defendant’s Court Name: Defendant’s True Name: Docket No.: District: Judge/Magistrate: Sentencing Date: USPO: Arrest Date: Assistant U.S. Attorney (Name, address, telephone) Defense C ounsel (Name, address, telephone) DEFENDANT’S IDENTIFICATION Defendant’s Names: (List every name the defendant has used, e.g., name given at birth, name given at adoption, nickname, alias, names used as a result of marriage, etc.) Date of Birth: Race: Age: White Black American Indian/Alaskan Native Asian or Pacific Islander Sex: Hispanic Origin: Unknown Hispanic Country of Citizenship: No. of Dependents: FBI No.: Place of Birth: Not Hispanic Unknown Immigration Status: Education: SSN: U.S. Marshal’s No.: Other ID No.: Defendant’s Legal Address: (Number and Street) (Apartment) (City) (State) (Zip) Defendant’s Current Address: (Number and Street) (Apartment) (City) (State) (Zip) Referral Date: Interview Date: 1 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) 2. OFFENSE DATA (Presentence Report Part A) CHARGES AND CONVICTIONS RELEASE STATUS Date Information/Indictment Filed: Check the Appropriate Box(s): Date of Conviction: In federal custody since In non-federal custody since Released on Unsecured personal recognizance $ personal recognizance bond since Count No.(s): Conviction by (Check one): Guilty Plea/Plea of Nolo Contendere Court Trial Verdict Jury Trial Verdict $ cash security since $ corporate security since $ property bond since Pretrial services supervision COUNTS OF CONVICTION Count Nos. Offense Classification Offense and Statutes Minimum/Maximum Statutory Penalty DETAINERS No Detainers Agency or Court Type of Detainer Case Number CODEFENDANTS No Codefendants Codefendant(s) Name(s): RELATED CASES (Co-offend ers) No Related Cases Docket No. Defendant(s) Name(s) 2 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) PLEA AGREEMENT Check One: Notes: Written Accepted Oral Deferred No Agreement Binding Substantial Assistance Motion: No Yes OFFENSE CONDUCT VICTIM IMPACT No Loss Victim’s Name Financial Loss Victim’s Address Victim’s Phone $ Loss to All Victims: $ Describe any social, psychological, or medical impact upon the victim of the offense behavior. ACCEPTANCE OF RESPONSIBILITY Defendant’s statement regarding offense: 3 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) 3. DEFENDANT’S CRIMINAL HISTORY (Presentence Report Part B) None Date of Arrest, Prosecution, Referral, or Detention Charge/ Conviction Court City/County/State Action No. Date Sentenced or Case Disposed Defendant Represented by or Waived Counsel (Y) or (N) 9 Sentence PENDING CHARGES AND SUPERVISION STATUS The defendant has no pending charges. Charge(s) Court Docket/Action No. Next Appearance Date The defendant is not currently under supervision. (division, probation, supervised release, or parole supervision) The defendant is currently under criminal justice sentence. Type of Supervision: Diversion Probation Supervised Release Parole Escape Status In Custody Jurisdiction(s): Supervising Officer’s Name and Telephone Number: 4 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) 4. OFFENDER CHARACTERISTICS (Presentence Report Part D) DEFENDANT Residential History: (List every town or city where the defendant has lived.) PARENTS AND SIBLINGS (List the defendant’s biological parents. If defendant was reared by persons other than his natural parents, add the surrogate parent’s names immediately below the space allocated to Father and Mother. After the parents, list all siblings, living or dead.) Name Relationship and Age Present Address and Telephone Number Occupation Father Current Name: Maiden Name: Mother Notes regarding family history; identify any significant problems: 5 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) MARITAL STATUS The defendant is presently single and has no marital history. Spouse or Domestic Partner Date and Place of Marriage Status Date of Separation Date of Divorce Court Where Divorce was Granted Number of Children Employment status of current spouse: CHILDREN The defendant has never had any children. Child’s Name Name of Other Parent of this Child Age Custody/ Support Child’s Address and Telephone Number (If different from defendant) Note health problems, criminal history, substance abuse, or any other significant information. 6 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) DEFENDANT’S PHYSICAL CONDITION PHYSICAL DESCRIPTION Height: Weight: Eye Color: Hair Color: Tattoos: Scars: PHYSICAL HEALTH The defendant is healthy and has no history of health problems. List the date(s) and nature(s) of any serious or chronic illnesses and medical conditions. List all current prescriptions. Provide the name, address, and telephone number of the defendant’s physician. MENTAL AND EMOTIONAL HEALTH The defendant has no history of mental or emotional problems, and no history of treatment for such problems. Describe any past or present mental, emotional, or gambling problems. Include the diagnosis of any problems (if known) and the dates of any treatment. List the name and address of the treatment provider. 7 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) SUBSTANCE ABUSE The defendant has no history of alcohol or drug use and no history of treatment for substance abuse. Which of the following substances has the defendant used? Alcohol Heroin/Opiates Marijuana Barbiturates Cocaine Hallucinogens Crack Inhalants Amphetamine/ Methamphetamine Other: When was alcohol or any controlled substance last used? Which substance does the defendant prefer? Which substance has caused the defendant the most problems? Urine test results: Describe in detail the defendant’s history of substance abuse and treatment. (Overdose, daily cost to support habit, frequency and quantity of use, treatment programs and dates) 8 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) EDUCATION AND VOCATIONAL SKILLS Highest grade completed: SCHOLASTIC HISTORY Name and Location of School (List most recent school first) Dates Attended Degree, Diploma, or Certificate Received Does the defendant have any specialized training or skill(s)? Yes No If yes, what training or skill(s)? Does the defendant have any professional license(s)? Yes No If yes, what license(s)? MILITARY None Branch of Service: Service Number: Entered: Discharged: Highest Rank: Rank at Separation: Decorations and Awards: Type of Discharge: VA Claim Number: Summarize the defendant’s military service. Describe any courts martial or non-judicial punishments. Describ e any foreign or comb at service. Describe any special training or skills acquired in the service. Describe previous VA claims. 9 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) EMPLOYMENT Defendant’s usual occupation: Defendant’s employment status: At the time of the offense, the defendant was (select the appropriate number from the categories below) At present, the defendant is (select the appropriate number from the categories below) 1. Employed full-time 2. Employed part-time 3. Unemployed temporarily, looking for work 4. Unemployed seasonal worker 5. Unemployed due to disability 6. Unemployed, history of extensive unemployment 7. Incarcerated or confined 8. Student 9. Homemaker 10. Retired 11. Other (Specify): FINANCIAL CONDITION/ABILITY TO PAY Refer to Form 48A Defendant has few assets and liabilities. EMPLOYMENT HISTORY (Describe the defendant’s employment history for the last ten years) Dates Name and Address of Employer Job, Monthly Wage, Reason for Leaving From: To Present Phone No.: From: To: From: To: From: To: 10 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) EMPLOYMENT HISTORY (Continued) From: To: From: To: From: To: From: To: From: To: From: To: Summarize any employment history over 10 years old: 11 American LegalNet, Inc. www.USCourtForms.com OPROB 1 (Rev. 4/01) NOTES: 12 American LegalNet, Inc. www.USCourtForms.com