INSTRUCTIONS FOR PERSONS REFERRED TO THE PROBATION OFFICE ‘The Judge has referred you to this office for completion of a presentence report. The Judge would like to know more about you and how you became involved in this case. This is your opportunity to tell the Judge about yourself. Te information you provide will help the Judge reach a decision regarding an appropriate sentence for you and may affect your eligibility for certain community supervision and/or Bureau of Prisons programs. ‘To help prepare your presentence report for the Judge, please complete the enclosed Presentence Interview Form and financial forms and bring them with you to your presentence interview with the probation officer. To help the probation officer with your presentence report, please provide us with copies of the following documents that pertain to you: + Birth or baptismal certificate + School diplomas, + Proof of residence (rent receipts, property and mortgage papers ete.) + Military discharge certificate + Military disability information + Marriage certificate(s) + Divoree decrees) + Social Security number + Immigration papers or passport + Naturalization papers + Income tax retums for the past 3 years + Employment verification (paystubs) + Professional papers (certificates, licenses, or permits) + Car registration papers + Medical reports (if curently under a doctor's care) + Department of Human Services recordsUNITED STATES DISTRICT COURT PROBATION AND PRETRIAL SERVICES NORTHERN DISTRICT OF TEXAS Presentence Interview Form ‘Section To Be Completed By US. Probation Office Date of Interview: Atty Present: Yes QNo Interpreter Location; J FDC 1 Probation Office [Teleconference [] Video conference [1 Oter Clients Telephone Nos (Come) (Cattle) Photographed: ©) Yes QNo — PACTSNe. prs offer: Home ispection: © Yes © No Cone Name case No. dg Maps: Arest Dat: Sentence Dae: aI Nos | Marsal No (ter 1D Na, PAUSA: Defease Counsel Retsiaed Ck Appointed Phone Phone Emit Fs ‘The information you provide may affect your sentence and eligibility for certain Hurean of Prison programs ‘Identification Data [Your Name (List every name you bave use, © game given abr, ame given at adoption, nickname, alias, names used as aresul of mariage, ce) Date of Birt: Sex © Fenule Place of Bist (ity and state) © Male D Unknown County: Roce: White OB OAs OladivEskine Qoter — OUainown Hispanic Origin Occasion © Cunese — Qtapnese Flips OKoran © Viewanese Otwpane © NonsHiopae Ciena Osamean Porto ean ©) Mercan © Porguse 5 Unknown Marital Stans Country of Citizenship Jenmigrstion Sts: O Sale * oun OUS Citnen O Divorced oer [No.of Dependants: Highest Level of Education: Social SecurityYour Primary Address: (te you’) (Nanbersnd Stee) (pene) ) (sa) ip) Your E-mail Address: How long have you been at this address? enti other people who reside at this ares an their relationship t you, ‘Are there any hazacds in the home? Ge. firearms, dangerous weapons, dogs, snakes, reptiles, ete.) Adress at time of offense: (umber nd See) (Aparmen) ccm sa) a How long have you been at this adress? deatfy other people who lived with you st tm ofthe offense? Family Verification Contact Person: Name Relation: Phone: (Comment Background and Characteristics Self ‘Residential Hisiory: (Provide a chronological history of counties, cities and slates where you have lived and the approximate year or age ‘ring which you lived there)Parents and Siblings List you biological parents, adoptive, Foster or legal guardians, and all siblings, half-sibtings or stepsiblings, alive or deceased. Name Relotiouship [Age | AddressTelephone Number (Occupation Father Carve Mother Maiden: | 08) 08) Oe|/e|oe Family History Describe who raised your; where you were mised; any significant problems during your childhood (i. neglestor abuse): were your material cede met? 1s your family aware ofthe instant case and are they supportive of you? Tn what ways ae they supportive of you? Describe any significant ealth problems, criminal history, substance abuse, or ther problems within your family, ‘Who do you spend most of your time with?“Marital Status [Check if you are presently single and have never been married Age of spouse ‘Number of [sum ‘Spouse or Domestic Partuer [Date and place of marriage |or partuer Date and Place of Divorce _| children |contact? a (Ey eS a a a ea ‘What was the reason for marriageirelationship ending? ‘Who in your relationships makes decisions? ‘Describe your relationship with current partaer: Deseribe employment of curent partner: ‘Does partaer have emia history? History of substance abuse/mental illness? Where and with whom do you plan to live with inthe future?Children [Cesk if you bnve never ad any children Child's Name ‘Parent Age Current Residence Describe whether your children, stepchildren, or other children you support have health problems, criminal history, substance abuse, and eseribe your fomily relationships, ete. 1f applicable, describe child support, physicaUlegal custody and visitation isues. ‘What stephildren did you help rise? ‘What impact has your behavior had ou others? ‘What are your fare plans regarding family, child care, cto?Physical Description Height: Weight yes! Hair: DirchmaskelDisinguishing Marks [Sear "Tattoos and location on body: Physical Health TT Ghesk if you ae healthy nd have no history of bealh problems, ‘deatfy all serous or chrouieillesses and/or medical conditions; hospitalizations or surgeries; aud approximate time frame of diagnoses snd treatment. Lis all current presriptions or medications. List any allergies to food or mei Provide physisian(s) name, address and telephone number; and approximate time fame of reaiment,‘Mental and Emotional Health [1 Cheek if you have no history of mental or emotional problems, and no history of treatment for such problems. Indicate if you wish to receive counseling or mental heath treatment for any specific problems, Deseribe any pastor preseut mentel or emotional health issues, to include any present suicidal thoughts and atempts Also include a description ofthe diagnosis of any problems (if known) and time frame, Describe past and present addictive problems (ie: gambling, compulsive disorder, ete), if applicable, Provide the dates (year) of your participation in eonnseling or restment and list the name and address ofthe treatment provides. ‘What have you leamed from previous or current participation in counseling or treatment?‘Substance Abuse [Cheek i yon do not havea history of aleahol or drug se and no history of treatment for substance abuse, ‘Are you interested in receiving substance abuse treatment? Tso, what do you hope to Team by attending treatment? Describe your participation in substance sbuse tvatmiet and/or drug testing while ou boul Aleobol Amphetamine/Metharapetamine ooo arbinaates Cocaine rnc Hallucinogens (C2, 1SD,auvooms, et) Heroin/Opiates Inhalants Marijuana Prescription Drugs oboooo Bsctaey | Other gKeamine, GHB.) Indicate whether you previously received outpatient or residential substance abuse trestiment Where ad when? Di you complete the program? Were you clinically discharged? ‘Were you under the influence ofilieit substances or aleobol when the offense ovcured? Di your use of drugs/alcabol contrite to your commission ofthe offense? In what way> ‘What do you need to doin order to refrain fiom further drug use?Education, Vocational and Other Skills, Highest grade complete: Scholastic History Name and Location of School Degree, Diploma or Cerificate Received [iE (ES) (aE ES] Di you participate in special education classes? Did you participate in any gifted programs?) No O Yes, lfyes, please list below. © Yes, Ifyes, please list below, Describe any other specialized training or skill.) (¢.. clerical, computer, welding, phunbing, CDL, self-defense, concealed handaun, ce) Identity your professional licenses) Describe your hobbies. ‘What are your future educational goals? ‘What type of vocational traning would you like to receive the unre? None Military Branch of Service: Highest Rank Date Discharged) Date Entered: Service Noniber Highest Ranke ‘Rank at Separation: ‘Desorations and Awards ‘VA Claim No. any Couti-Martial or now judicial punishments (Article 15), Describe previous VA claims, Deseribe your mitay service, to include foreign or combat servic. Deseribe any special training or skills aequited in the servi, Deseribe“Employment Employment History Describe your employment history forthe last ten yeas, including periods of unemployment ob Tine ~ Wages - Reason for leaving Start Date___[End Date [Euployer (aame and address) (Part-time or Full-time) Phone No. a a Phone No. fe a Phone No. Phone No. Phone No. a a Phone No. a a Phone No. Phone No.How did you support yourself during periods of Lf applicable, desoribe your sccpt of statelederl benefit to include ‘ood stage ancmplaymnen, Tears ec Abo elude he yea) pou eee these Bento “" | | i“Acceptance of Responsibility Deseribe how you have accepted responsibility for commiting the offense? Howr do you feel abont having committed this offense? the offense? ‘What influenced you to commit this offense? ‘What impact has your behavior had on others? How will you stay out of trouble? Lf applicable, what is your plan to make resttation?(Criminal History [None (No prior arests or convictions) Report any juvenile referrals, adjudications, placements and the dates, i applicable ‘Report ny criminal convitions, revs, and pending eases Defendant Date Represented Date of Ares, Seatenced or by oc Waived Prosecution, oF Court CityiCounty’State | Case Counsel Deteotion”-_|ChargelCoaviction Case No, Disposed __|Sentence () or) OS@/OR/5S/0S|0R/bR/58 ‘Are you curently under State or Federal supervision? — CQ) No. © Yes: If yes, plesse lst below ‘What programs have you paticipated in os a condition of supervision and/or while in custody? Describe your experience under supervision inthe past and present, if applicable.‘Additional Data About You ‘Since being charged in this case, what rehabilitative efforts have you made to change your life's path? Ifyou are sentenced toa tem of imprisonment, what will you focus on while in custody? ‘What are your foture plans regarding family and relationships? ‘What are your frre plans for employment? ‘What are your foture plans for treatment? ‘What are your firue plans for education? ‘What are your fiture plans as to your peers?‘Additional Information