crj 150 week 10

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ClientInformationPacket-SupplementtoProb1case3.pdf
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Supplement to PROB 1 (NYEP - 11/22)

Page 1 of 16

CLIENT INFORMATION PACKET

Having been convicted in the United States District Court, the Probation Department is required to complete a presentence investigation report for the court. The presentence investigation report will contain factual information relevant to your sentencing, including information regarding your personal history. To assist in that process, please complete this packet in its entirety. The information contained in this packet will be discussed with you in detail during the presentence interview and will be relied upon for the completion of your presentence investigation report. You may utilize additional pages to provide the requested information, if necessary.

In addition to incorporating the information contained in this packet and obtained from you during the presentence interview, your presentence investigation report will indicate the documentation you provided for corroborative purposes. As such, please provide photocopies (electronic photocopies preferred) of the below-noted documentation (if applicable).

 Birth certificate(s), for you and children  Immigration documents/naturalization certificate, if applicable.  Marriage certificate(s)/divorce decree(s)  Social Security card/ SSI benefits letter  Personal & corporate tax returns for past 3 years  Driver’s license and current car registration(s)  School records, including diplomas and any professional licenses or certifications  Any paperwork to confirm past AND present employment and other sources of income

(i.e.: paystubs, W-2 forms /welfare/disability award letters)  Medical records and prescription(s) list (from pharmacy), if currently under treatment for

any physical or psychiatric problems  Most recent bank statements for all accounts, investment account statements, credit card

bills and car/school loan payments.  Apartment lease or mortgage note, or other means to verify housing costs.  Resume.

Last Name First Name Middle Name Social Security Number

Supplement to PROB 1 (NYEP - 11/22)

Page 2 of 16

UNITED STATES DISTRICT COURT

Federal Probation System

SUPPLEMENT TO WORKSHEET FOR PRESENTENCE REPORT

PERSONAL IDENTIFICAITON

Name(s): (List every name you have used, e.g., name given at birth, name given at adoptions, nickname, alias, names used as a result of marriage, etc). Date of Birth:

Age: Place of Birth:

Race: ☐White ☐ Black ☐ American Indian/Alaskan Native Hispanic Origin: ☐Yes ☐No ☐ Asian or Pacific Islander ☐ Other

Sex:

SSN: Immigration Status:

Country of Citizenship:

Other ID #:

Current Legal Address: ____________________________________________________ (Number and Street, Apartment Number if applicable) _________________________________________________________ (City) (State) (Zip) Current Residence Address: ☐ Same as above ☐ Rent ☐Own ____________________________________________________ (Number and Street, Apartment Number if applicable) _________________________________________________________ (City) (State) (Zip)

Pretrial Officer Name (if applicable):

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Supplement to PROB 1 (NYEP - 11/22)

Page 3 of 16

RESIDENCE HISTORY (Please indicate the last three locations you resided, other than your current address)

Address: ____________________________________________________________________ Number/Street/Apartment Number (if applicable) City/State/Zip ☐ Rented ☐ Owned

Dates Resided: Address: ____________________________________________________________________ Number/Street/Apartment Number (if applicable) City/State/Zip ☐ Rented ☐ Owned

Dates Resided: Address: ____________________________________________________________________ Number/Street/Apartment Number (if applicable) City/State/Zip ☐ Rented ☐ Owned

Dates Resided: Please summary residence history: City/State/Country, Approximate Dates Resided.

Supplement to PROB 1 (NYEP - 11/22)

Page 4 of 16

PARENT/SIBLING INFORMATION

Name Age Residence (City/State)/Phone #

Occupation

Health

Father

Mother

SIBLINGS

Supplement to PROB 1 (NYEP - 11/22)

Page 5 of 16

ADDITIONAL FAMILY DATA

Provide contact information for any stepparents, adoptive parents, adopted siblings, guardians, etc. (if applicable), or any other relevant family data.

Supplement to PROB 1 (NYEP - 11/22)

Page 6 of 16

MARITAL/ROMANTIC RELATIONSHIP HISTORY

☐ Presently single and no marital/relationship history. Name Age Residence

(City/State)/ Phone #

Occupation/ Income

Dates of Relationship

# of Children

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

Supplement to PROB 1 (NYEP - 11/22)

Page 7 of 16

CHILDREN (Parent/Guardian of minor children will be contacted by the U.S. Probation Department)

☐ No Children Child 1 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No Child 2 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No Child 3 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No Child 4 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No

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Supplement to PROB 1 (NYEP - 11/22)

Page 8 of 16

CHILDREN (continued)

Child 5 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No Child 6 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No Child 7 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No Child 8 Name: Age: Name of Other Parent/Guardian: Address (City/State, if not residing with you): Student: ☐ Yes ☐ No Custody: ☐ Yes ☐ No Employed: ☐ Yes ☐ No Financial Support Provided: ☐ Yes ☐ No

Supplement to PROB 1 (NYEP - 11/22)

Page 9 of 16

PHYSICIAL CONDITION

☐ Healthy and no history of health problems. List the date(s) and cause(s) of any serious chronic illnesses and medical conditions (past and present). For any prior hospitalizations, be sure to indicate where and for how long. List all current prescriptions. Name, address, and telephone number for all physicians.

Supplement to PROB 1 (NYEP - 11/22)

Page 10 of 16

MENTAL AND EMOTIONAL HEALTH

☐ No history of mental or emotional health 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(s).

List all current prescriptions.

Supplement to PROB 1 (NYEP - 11/22)

Page 11 of 16

SUBSTANCE ABUSE

☐ No history of alcohol or drug use and no history of treatment for substance abuse ☐ Declines to discuss alcohol or drug use. NOTE: Failure to discuss issues relating to alcohol and drug use could preclude you from treatment programs within the BOP. Describe in detail history of substance abuse and treatment. (Overdose, daily cost to support habit, frequency and quantity of use, treatment programs and dates). Substance First Used Last Used How Often/How much? Alcohol

Marijuana

Powder Cocaine

Crack Cocaine

Heroin

Opiates

Other (please specify)

Other (please specify)

Other (please specify)

Which substance did you use most frequently?

Which substance(s) has/have caused you the most issues/problems?

Describe in detail history of substance abuse treatment. (Indicate name/dates and duration of programs and if successfully completed or not.)

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Supplement to PROB 1

(NYEP - 11/22)

Page 12 of 16

EDUCATION AND VOCATION SKILLS

Highest Education Level: Fluent Language(s):

Name of School City/State/Country Dates Attended Degree, Diploma or

Certificate Received

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

Do you have any specialized training or professional licenses?

☐Yes ☐No If yes, please describe below.

MILITARY

☐ None.

Branch of

Service

Service Number Date Entered Date

Discharged

Discharge Type

Highest

Rank

Rank at Separation Decorations/Awards VA Claim Number

Summarize Military Service.

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Supplement to PROB 1 (NYEP - 11/22)

Page 13 of 16

EMPLOYMENT HISTORY

Dates Name/Address of Employer Title/Position; Reason for Leaving

From: Position/Title:

Reason for Leaving: To: Present Weekly Hours:

Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From: Position/Title:

Reason for Leaving: To: Weekly Hours:

Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From: Position/Title:

Reason for Leaving: To: Weekly Hours:

Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From: Position/Title:

Reason for Leaving: To: Weekly Hours:

Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From: Position/Title:

Reason for Leaving: To: Weekly Hours:

Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

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Supplement to PROB 1 (NYEP - 11/22)

Page 14 of 16

EMPLOYMENT HISTORY (continued)

From:

Position/Title: Reason for Leaving:

To: Weekly Hours: Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From:

Position/Title: Reason for Leaving:

To: Weekly Hours: Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From:

Position/Title: Reason for Leaving:

To: Weekly Hours: Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From:

Position/Title: Reason for Leaving:

To: Weekly Hours: Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

From:

Position/Title: Reason for Leaving:

To: Weekly Hours: Gross Salary: ☐ Weekly ☐ Biweekly ☐ Annually

Supplement to PROB 1 (NYEP - 11/22)

Page 15 of 16

EMPLOYMENT HISTORY (continued) Please summarize all additional prior employment prior to the last 10 years. Please indicate dates of prior unemployment and means of financial support during that time.

Supplement to PROB 1 (NYEP - 11/22)

Page 16 of 16

ACCEPTANCE OF RESPONSIBILITY STATEMENT ☐ Declined to provide a statement regarding the offense. Statement regarding the offense:

  1. Last Name:
  2. First Name:
  3. Middle Name:
  4. P2-1:
  5. Date of Birth_af_date:
  6. Age:
  7. POB:
  8. Sex:
  9. Social Seccurity NUmber:
  10. Country of Citizenship:
  11. Other ID:
  12. Current Legal Address:
    1. 1:
  13. City:
    1. 0:
    2. 1:
  14. State:
    1. 0:
    2. 1:
  15. Zip Code:
    1. 0:
    2. 1:
  16. Same as Current Residence?: Off
  17. Rent or Own: Off
  18. Pretrial Officer Name:
  19. Residence History 1:
    1. 0:
    2. 1:
    3. 2:
  20. Rent or Own 1: Off
  21. Dates Resided 1:
    1. 0:
    2. 1:
    3. 2:
      1. 0:
  22. Rent or Own 2: Off
  23. Rent or Own 3: Off
  24. Residence History:
  25. Text3:
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            11. 10:
  29. ADDITIONAL FAMILY DATA:
  30. Single-No Marital: Off
  31. Text11:
    1. 0:
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  32. Text12:
    1. 0:
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        1. 0:
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            13. 12:
    2. 1:
      1. 0:
        1. 0:
          1. 0:
            1. 0:
            2. 1:
            3. 2:
            4. 3:
            5. 4:
            6. 5:
            7. 6:
            8. 7:
            9. 8:
            10. 9:
            11. 10:
            12. 11:
            13. 12:
  33. Child 1:
    1. Name:
    2. Age:
    3. OtherParentName:
    4. Address:
  34. Student1: Off
  35. Employed1: Off
  36. No Children: Off
  37. Child 5:
    1. Name:
    2. Age:
    3. Address:
    4. OtherParentName:
  38. Student5: Off
  39. Employed5: Off
  40. Custody5: Off
  41. Financial Support Provided5: Off
  42. Child 6:
    1. Name:
    2. Age:
    3. Address:
    4. OtherParentName:
  43. Student6: Off
  44. Employed6: Off
  45. Custody6: Off
  46. Financial Support Provided6: Off
  47. Child 7:
    1. Name:
    2. Age:
    3. Address:
    4. OtherParentName:
  48. Student7: Off
  49. Employed7: Off
  50. Custody7: Off
  51. Financial Support Provided7: Off
  52. Child 8:
    1. Name:
    2. Age:
    3. Address:
    4. OtherParentName:
  53. Student8: Off
  54. Employed8: Off
  55. Custody8: Off
  56. Financial Support Provided8: Off
  57. Child 4:
    1. Name:
    2. Age:
    3. OtherParentName:
    4. Address:
  58. Student4: Off
  59. Employed4: Off
  60. Custody4: Off
  61. Financial Support Provided4: Off
  62. Child 3:
    1. Name:
    2. Age:
    3. Address:
    4. OtherParentName:
  63. Student3: Off
  64. Employed3: Off
  65. Custody3: Off
  66. Financial Support Provided3: Off
  67. Child 2:
    1. Name:
    2. Age:
    3. OtherParentName:
    4. Address:
  68. Student2: Off
  69. Employed2: Off
  70. Custody2: Off
  71. Financial Support Provided2: Off
  72. Custody1: Off
  73. Financial Support Provided1: Off
  74. No Health History: Off
  75. Chronic Illnesses List:
  76. Current Prescriptions List:
  77. Physicians List:
  78. No Mental Health History: Off
  79. mental, emotional, or gambling problems:
  80. Current Prescriptions-Mental:
  81. No Alcohol and Drug Use History: Off
  82. Declines to discuss alcohol and drug use: Off
  83. FirstUsed1:
    1. 0:
    2. 1:
    3. 2:
    4. 3:
    5. 4:
    6. 5:
    7. 6:
    8. 7:
    9. 8:
  84. Text7:
    1. 2:
      1. 0:
      2. 1:
      3. 2:
      4. 3:
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      6. 5:
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      8. 7:
      9. 8:
  85. HowMuchHowOften1:
    1. 0:
    2. 1:
    3. 2:
    4. 3:
    5. 4:
    6. 5:
    7. 6:
    8. 7:
    9. 8:
  86. Subs1:
    1. 6:
    2. 7:
    3. 8:
  87. Substance use most frequently:
    1. 0:
    2. 1:
    3. 2:
  88. School1:
    1. 0:
      1. 0:
        1. 5:
          1. 0:
        2. 0:
        3. 1:
        4. 2:
        5. 3:
        6. 4:
      2. 1:
        1. 0:
        2. 1:
        3. 2:
        4. 3:
        5. 4:
        6. 5:
      3. 2:
        1. 0:
          1. 0:
          2. 1:
          3. 2:
          4. 3:
          5. 4:
          6. 5:
        2. 1:
          1. 0:
          2. 1:
          3. 2:
          4. 3:
          5. 4:
          6. 5:
    2. 1:
      1. 1:
        1. 5:
          1. 1:
            1. 0:
            2. 1:
  89. specialized training: Off
  90. Service Branch:
    1. 0:
      1. 0:
        1. 1:
          1. 0:
          2. 1:
          3. 2:
          4. 3:
        2. 0:
      2. 1:
      3. 2:
      4. 3:
    2. 1:
      1. 0:
  91. Fluent Languages:
  92. No MIlitary: Off
  93. Weekly Hours:
    1. 6:
    2. 7:
    3. 8:
    4. 9:
    5. 10:
    6. 5:
    7. 1a:
    8. 2:
    9. 3:
    10. 4:
  94. Gross Salary:
    1. 4:
    2. 6:
    3. 7:
    4. 8:
    5. 9:
    6. 1a:
    7. 2:
    8. 3:
    9. 5:
    10. 10:
  95. Emp6:
  96. EmpPos6:
  97. EmpLeave6:
  98. EmpDateF6:
  99. EmpDateP6:
  100. EmpDateF7:
  101. Emp7:
  102. EmpPos7:
  103. EmpLeave7:
  104. EmpDateP7:
  105. EmpDateF8:
  106. Emp8:
  107. EmpPos8:
  108. EmpLeave8:
  109. EmpDateP8:
  110. EmpDateF9:
  111. Emp9:
  112. EmpPos9:
  113. EmpLeave9:
  114. EmpDateP9:
  115. EmpDateF10:
  116. Emp10:
  117. EmpPos10:
  118. EmpDateP10:
  119. EmpLeave10:
  120. Salary1: Off
  121. EmpDateF2:
  122. Emp2:
  123. EmpPos2:
  124. EmpDateP2:
  125. EmpLeave2:
  126. Salary2: Off
  127. EmpDateP5:
  128. EmpDateF5:
  129. Emp5:
  130. EmpPos5:
  131. Salary5: Off
  132. EmpLeave5:
  133. EmpDateF3:
  134. Emp3:
  135. EmpPos3:
  136. EmpDateP3:
  137. EmpDateF1a:
  138. Emp1a:
  139. EmpPos1a:
  140. EmpDateP1a:
  141. EmpLeave1a:
  142. EmpDateF4:
  143. Emp4:
  144. EmpPos4:
  145. EmpLeave4:
  146. EmpDateP4:
  147. Salary4: Off
  148. Salary3: Off
  149. EmpLeave3:
  150. Salary6: Off
  151. Salary7: Off
  152. Salary8: Off
  153. Salary9: Off
  154. Salary10: Off
  155. Emp Histoy:
    1. 0:
    2. 1:
  156. Declined Offense Statement: Off
  157. Offense Statement:
  158. Text9:
    1. 0:
      1. 0:
        1. 0:
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        13. 12:
  159. Text10:
    1. 0:
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        7. 6:
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        9. 8:
        10. 9:
        11. 10:
        12. 11:
        13. 12:
  160. American Indian/Alaskan Native: Off
  161. Black: Off
  162. Whit: Off
  163. Hispanic Origin: Off
  164. Asian or Pacific Islander: Off
  165. Other: Off
  166. Ammigration Stats: []
  167. Legal Address:
  168. Highest Education Level: [ ]
  169. Degree, Diploma or Certificate:
    1. 0:
    2. 1:
    3. 2:
    4. 3:
    5. 4:
    6. 5: