EFTA01097984.pdf

di111I8)LIII ID:33216 State of New York Division of Criminal Justice Services 4 Tower Place Albany, NY 12203.3764 SINGLP 120 2 1 SP 0.440 001 III II I I I II 111..111..1111_.111. To: JEFFREY EPSTEIN April 11, 2011 6100 RED HOOK QUARTERS, SUITE 83 Offender ID: 33216 ST THOMAS VI 00802 From: Sex Offender Registry Unit, NYS Division of Criminal Justice Services RE: Annual Address Verification Sex Offender Registry Annual Address Verification Form The Sex Offender Registration Act (SORA) requires you to review, update, and sign this Annual Address Verification Form and mail this form back to the Division of Criminal Justice Services within 10 days from receipt of this form. You must do this whether or not you have reported updated information to parole, probation or a law enforcement agency. If you attend, are enrolled at, reside at, or are employed at any institution of higher education, you must provide that information on this form. You must also report your internet service provider(s), all screen names, all e-mail addresses and all other information listed on the form. If you are a level 3 sex offender, you must report the name and address of all employers. INSTRUCTIONS: 1) Review each line of information on this form carefully. 2) If you find any information that is incorrect or outdated, cross out incorrect or outdated information with a single line. 3) Enter any corrections or any new/additional information in the blank boxes provided. THIS FORM MUST BE SIGNED AND ALL PAGES RETURNED EVEN IF NONE OF THE INFORMATION HAS CHANGED. FAILURE TO RETURN ALL PAGES OF THIS FORM WITHIN 10 DAYS OF RECEIPT IS A FELONY AND MAY RESULT IN THE ISSUANCE OF A WARRANT FOR YOUR ARREST. Please contact the Sex Offender Registry at 518-457-3167 with any questions about this form. OFFENDER INFORMATION LAST NAME FIRST NAME MIDDLE SSN Mak* EPSTEIN JEFFREY EDWARD corrector+. OTHER NAMES EPSTEIN,JEFFREY EDWARD Enter any aliases, nick names or other names used in the following section. Page • 1 • of EFTA01097984  II LIN1000000378 ID:33216 499 PHYSICAL ATTRIBUTES BIRTHDATE HEIGHT WEIGHT HAIR EYES GLASSES 01 /2011953 600 180 Gray Blue make =moons <— Fere SCARS/MARKS/TATTOOS Enter any other scars/marks/tattoos. PRIMARY ADDRESS Primary address is the address where you live most of the time. NUMBER/STREET/APT CITY 6100 RED HOOK QUARTERS.SUITEB3 ST THOMAS Make correciions <.— 1 here STATE ZIP COUNTY COUNTRY VI 00802 US Make conscaora <— here Phone II at this address: (561) 655- 7621 Enter phone • correction here --> Name of College / University. TELEPHONE NUMBER Enter the phone number where you can be reached in the following section. Page • Of 6 EFTA01097985  ID:33216 IIIIII111111111 99I SECONDARY ADDRESS ndary Address is the address where you live some of the time. NUMBER/STREET/APT CITY 9 E 71ST ST NEWYORK JAM* correcilons 1 <— here STATE ZIP COUNTY COUNTRY MSG NY 100214102 New York US corredons Phone a at this address: Enter phone a correction here —> Name of Cane / Uriversity: NUMBER:STREET/APT CITY 358 EL BRIL I.O WAY PALM BE :CH Make ecereelIcos 2 <- here STATE ZIP COUNTY COUNTRY Make FL 33480 correetises Phan, a et din leideette II-ter phone a correctio here ----. Name of College I University: NUMBER/STREETIAPT CITY Make CeireCilant 3 <- hare STATE ZIP COUNTY COUNTRY FN Make corrections e— hen) Phone Hat this address: I Ellen phone ll correction here —> Name of College! University: NUMBER/STREET/APT CITY 49 ZORRO RANCH RD STANLEY Use corecuors STATE ZIP COUNTY COUNTRY NM 87093 US Phone 0 at this address: Enter rtione e correction hero --> Name of College f University: Enter any additional Secondary Address in the following section NUMBER/STREET/APT C IT 1 STATE ZIP COUNTY COuN TRY Enter phone a here -> If the above address Is on the campus of a College or Univervty.enter its nary° NUMBERISTREET/APT Cr I 2 STATE ZIP COUNTY f CCUNTNY Enter phone a here —a If the above address is on the campus of a College or Un,vers :y.enter its name Page - 3 • of 6 EFTA01097986  919 1O:33216 11,1111111,11 PO BOX ADDRESS PO Box Address is allowed if mail cannot be delivered to the primary address. PO Box Address must be approved by the Post Master and Law Enforcement. Enter any PO BOX Information in the following section PO BOX CITY 1 STATE ZIP COUNTY COUNTRY EMPLOYMENT INFORMATION Enter any additional employment information in the following section EMPLOYER'S NAME NUMBER/STREET/APT 1 CITY STATE ZIP COUNTY COUNTRY Enter phone a here --> If the above address is on the campus of a Col!ege or Unwersly.enter its name EMPLOYERS NAME NUMBER/STREET/APT 2 CITY STATE ZIP COUNTY COUNTRY Enter phone a here --> If the above address is on the campus of a College o Universthr.enter As name HIGHER EDUCATION INFORMATION Higher education includes any 2 or 4 year colleges or any trade or vocational schools. Enter any additional education information in the following section SCHOOL NAME NUMBER/STREET/APT 1 CITY STATE ZIP COUNTY COUNTRY Enter phone # here --> SCHOOL NAME NUMBER/STREET/APT 2 CITY STATE ZIP COUNTY COUNTRY Enter phone ft here --> VEHICLE INFORMATION Information of any vehicle that you own or drive. Enter any additional vehicle information in the following section YEAR MAKE MODEL COLOR LIC PLATE STATE Page - 4 - of 6 EFTA01097987  37I8)99I111 t)1 1101,1, ID:33216 DRIVER'S LICENSE INFORMATION Enter any additional drivers license information in the following section DRIVER'S ISSUING STATE LICENSE NUMBER INTERNET INFORMATION SERVICE PROVIDER SERVICE PROVIDER AT&T Make correcians <--- here FREE Make correetrons <— here ORAUGE TELECOM make e<ineeLOns <— here COMCAST Make COrreCLOCIS 4— here SPRINT Make oarrecbals <— here TIME WARNER Make corrocbco> <— here EMAIL ADDRESS E-MAIL ADDRESS mak* carechanr C.— here Make CarOCCOIS C.- two Make JEEVACATIONQGMAILCOM CMCOO'S <.- Pyre Page -5 - of 6 EFTA01097988  ID:33216 Enter any additional Internet information in the following section RPRII SERVICE PROVIDER SCREEN NAME E-MAIL ADDRESS I CERTIFY THAT THE INFORMATION ON THIS FORM IS COMPLETE AND ACCURATE. HAVE CROSSED OUT ALL INFORMATION THAT IS INCORRECT OR OUTDATED. I HAVE ADDED ALL CORRECTIONS AND ALL NEW INFORMATION. I UNDERSTAND THAT FAILING TO PROVIDE THIS INFORMATION OR PROVIDING FALSE INFORMATION IS A FELONY. Sex Offender's Sex Offender's Date Signature Name(print) THIS FORM MUST BE SIGNED AND ALL PAGES RETURNED EVEN IF NONE OF THE INFORMATION HAS CHANGED. FAILURE TO RETURN ALL PAGES OF THIS FORM WITHIN 10 DAYS OF RECEIPT IS A FELONY AND MAY RESULT IN THE ISSUANCE OF A WARRANT FOR YOUR ARREST. Return to: Division of Criminal Justice Services - SOR 4 Tower Place Albany, NY 12203-3764 Page - 6 -of 6 EFTA01097989