EFTA00609343.pdf

NEW YORK STATE cPx. nFFFNnFRP-cl-nP INFORMATION As a registered sex offender, you must provide the New York State Division of Criminal Justice Services (DOS) with your internet accounts including the internet service provider (ISP) you use and any e-mail addresses and screen names used by you for the purposes of chat, instant messaging, or social networking. 1. Sex Offender's Name (print) 2. Date of Birth . Tauway.{ Jo, lcS-S C. CCrt i 7 .1 — epthei A 3. Current Address F .-,oennabit,..-i iges tckat,c t - L; Ole St •Lii.“ ot., Taxi,4:9 i cio bloc. Rod Stook ta Joe ki t Su. 4c. (1.-S.,_ SA • il.a.,,,.4 a s , ,...e.)1. o0502 Fiq ..' i f- k -71.4 Sivieek, NVIe vact i ma% 41,^ma. - Lon/ , ah.. 3n6a sm.. mg zer,,,,e,...t., go..„), 54-1 n VniS6 i Ft ^ a e Co ct-. , 44! I bbi AVIS, CA 7S-it (7 4. E-Mail address(es) (examples: dsmith@aol.com; Run4Fun@gmail.com; Sammy.Sample@nycap.rr.com) r te. face:boo. G. OVV‘0%; t. C.0 144.. j c.f...44tcakt ov% G Wit • Gov.& jte.. erojc.ci a tic. k o0 . fm.. 0 Check here, If you have no e-mail addresses. S. ISP (s) [examples: Frontier, Time Warner, NetZero, Comcast] wT - tient u3ory‘e v-, Se e/ 4- Ca,o w.co.c4) Or a 14 C% t 7-414 rata Fleee— / Aclir 0 Check here, if you have no internet service provider (ISP). • 6. Screen Name(s) [examples: Sam Sample, LoveMyTruck, Runner4Life, Dman429, Denny Smith, Artist12281 0 Check here, if you have no screen names. Be sure to list all e-mail accounts, ISPs and screen names. If you fall to report this information, you may be convicted of a class E felony. If you are convicted of a second or subsequent offense, you shall be guilty of a class D felony. Failure to report this Information may also be the basis for revocation of parole or probation. Use the back of this form if you need more space. If your information changes at any time, you must report that new information to DOS within ten (10) days of that change. Complete this form and mail It to: NYS Sex Offender Registry, 4 Tower Place Albany, New York 12203. A form without a signature will not be accepted and will be returned. "I acknowledge that the information provided on this form is true and accurate. I understand that offering false information or failing to provide the required information is a crime." Sex Offender's Signature Date EFTA00609343  NEW YORK STATE SEX OFFENDER E-STOP INFORMATION As a registered sex offender, you must provide the New York State Division of Criminal Justice Services (XIS) with your internet accounts including the internet service provider (ISP) you use and any e-mail addresses and screen names used by you for the purposes of chat, instant messaging, or. social networking. 1. Sex Offender's Name (print) 2. Date of Birth _ Tqb --t C? r. • ) / -2,:-),J ri 3. Current A dress . . / CACI -n 7( 4. E-Mail address(es) [examples: dsmith@aol.com; Run4Fun@gmail.com; Sammy.Sample@nycap.rr.com] r S Ct—C-- kiraC c-/-t r cr 3 6 ',nil o Check here, If you have no e-mail addresses. S. ISP (s) (examples: Frontier, Time Warner, NetZero, Comcast) . - ( Vi.., (.--k ) vefre- - ' . . 0 Check here, if you have no Internet service provider (ISP). 6. Screen Name(s) [examples: Sam Sample, LoveMyTruck, Runner4Life, Dman429, Denny Smith, Artist1218] . - co Check here, if you have no screen names. Be sure to list all e-mail accounts, ISPs and screen names. If you fail to report this information, you maybe convicted of a class E felony. If you are convicted of a second or subsequent offense, you shall be guilty of a class D felony. Failure to report this Information may also be the basis for revocation of parole or probation. Use the back of this form if you need more space. If your information changes at any time, you must report that new information to DOS within ten (10) days of that change.. Complete this form and mail it to: NYS Sex Offender Registry, 4 Tower Place Albany, New York 12203. A form without a signature will not be accepted and will be returned. "I acknowledge that the information provided on this form is true and accurate. I understand that offering false information or failing to provide the required information is a crime." —Th ciP — 7 ... roes Signat ure Date EFTA00609344