ALEASE PRINT OR TYPE -- Complete all sections, attach fingerprint card, photograph, and genetic markers when available, and submit to the Department of Justice, GERS Building, 2 Floor, St. Thomas, VI 00602 SECTION B - Contributing Agency Information SEXUAL OFFENDER/SEXUAL PREDATOR REGISTRATION FORM FOR USE BY LAW ENFORCEMENT AGENCIES SECTION A - Type/Status Sex Offender Agency Name: [ ] Habitual Sexual Offender Agency Address: [ ] Sex Predator | Phone Number: ( Fax:( ) { ] New Registration Checked for Warrants: { ] Local System [ ] FCIC.NCIC SYSTEM { ] Modify Data CCH for Sex Offenses: [ ] Yes [ ] No SECTION C - Registration Information Name: ersleys Tyg € Alias: ssn-070-YY-33YP pion gy 7 ast First pop:lts<? pop. ‘bey tare ViDrivers License: OOOO 25L7Y Ew date: 29 -/S~ MOY] Mov Race:_«__Sex__Ih Ht: & Wt. 1x Ha Loe, Eves w Scars, Marks, Tattoos: 0 [ ] YE Are You Registered as a Sex Offender in Another State: [JN S If YES, which state: SECTION D - Residence lay Physical Address: Evil 97. Qepen Mailing Address;_& 0 2 € Hoole’ Temporary Address: and at what LEVEL Closest Living Relative . - Name: Aarle Srlew Relationship: ig wf Ze? Address: 8 tay AP Contact #: Home: | Cellular. fF SECTION E - Employment [ ] Employed [ ] Unemployed tact Person: Employer: 1x @ Contact Person: - Address: is fea fish “pF Date Employment:/*- 9 3 Telephone SECTION F- Vehicle, Trailer, Vessel, Etc. Description (Year/Make/Model/Color Scheme) : License Plate#: VIN#: SECTION G - Offense Information VICTIM fp} Adult [ ] Minor [ ] Acquitted by Reason of Insanity a £ — mc Committed Place of Conviction Court/Court No. AG No. ba SPOT Fuava In the event there is a change in your permanent or temporary residence after initial registration and any subsequent changes thereafter, you must nolify the V.1. Department of Justice within three (3) days after arrival at your new residence. 4, In the event there is a change in your address outside the USVI, you must register your new address with the V.1. Department of Justice prior to departure and also register in your new jurisdiction within ten (10) days after establishing residence there if the new jurisdiction has a registration fequirement. 4. You are required to verify your address with the V.I. Department of Justice annually on the anniversary of your initial registration. If you were determined to be a sexually violent predator, you must verify your address with the V.1. Department of Justice every ninety (90) days after the date of your initial release or commencement of parole, 5. Failure to comply with the above requirements shall subject you to a fine of not less than $3,000.00 or imprisonment for not less than three (3) months or more than two (2) years, or both. Be Reminded that even if you may not be required to register under Virgin Islands Law, under Title | of the Adam Walsh Act entitled the "Sexual Offender Registration and Notification Act '(SORNA), all individuals convicted of a Sex offense are required to register and keep their fegistration current in each jurisdiction where he or she resides, is an employee and is a student. FAILURE TO DO SO MAY SUBJECT You To CRIMINAL PROSECUTION Registrant: Witness: | acknowledge that the above requirements as set forth have been | certify that | specifically informed the offender of his /hy explai . aboytand he indicated ome ay ndefStdnding pt pose ier duties as have set forth duties, , EFTA00304441