VIRGIN ISLANDS DEPAR IMENT OF JUSTICE oO THE ATTORNEY GENERAL VIRGIN SSENU AL OFFENDER REGISERY SEXUAL OFFENDER REGISTRATION FORM FOR USE BY LAW ENFORCEMENT AGENCIES PLEASE PRINT - COMPLETE ALL SECTIONS SECTION A - Tier/Status SECTION B SECTION B (0 Tier! { | New Registration { ] Parole { ] Tier! { ] Modify Data (j Probation { ] Tier lit ft Renewal Registration { } Supervised Release SECTION D - Registration Information — Name WA) 7 fay = _ Sh gd Alias ee Sant OPO-¥L UY niene FE -IY A Vi Driver's License#: E PIUR VET §2 DE7 -© Exp Date | [2ojiy We 7a bq Eyes _@y Scars. Marks. Tattoos: _ SECTIONE-Residence [ ] HOMELESS Closest Living Relative [ ]NIA Physical Address 2 Deevts 2s T Name: pry MailingAddress_ tod cd (buh sule KD Address Temporary Address: —— Contact #: Home: P22 EI Cellar 24.2% -Y)B | Contact # Home, —__ SECTION F - Internet Identifiers -List any and all email addresses used. Instant Messaging addresses and identifiers. designations or monikers in internet communications and postings, and all social network identifiers. [ ] NIA SECTION G - Employ ia [ ] Unemployed Employer Ergo — SP "Th Southern Trust Co.’ Contact Person: _ os ___._ Occupation Benker Telephone 33/~ 23 25- Address pOO fer jee Date Employment Employer _ _ Contact Person: (Occupation _ Telephone _ Address : a Date Employment: _ SECTION H - Volunteer Information Organization _ MN [Pe Contact Person _ Telephone — Address’ _ Organization _ Contact Person. __ Telephone ____ Address SECTION | - Occupational License Information [ JNIA S&e QWHac ned Date: _ . _ _____ Occupational License Issuer __ Dates Enrolled: SECTION K - Vehicle, Trailer, Vessel, Etc. [ ]NIA € Description (Year/Make/Model/Color Scheme) License Plate#: : Permanent/Frequent Location of Vehicle: EFTA00315044

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SECTION L ~ Offense Information VICTIM | } Adult [ ] Minor { ] Acquitted by Reason of Insanity n: nmi Victim e+ 30 Place of Conviction CourtiCourt No AS Ne if Ld] Ck Aew_ Are You Registered as a Sex Offender in another State: [ ] NO [ ] YES If YES, which state: _ andatwhatLEVEL SECTION M - PLEASE READ CAREFULLY BEFORE SIGNING As a Sexual Offencer (Title 14.V!C § 1721-1731) you are required by law to abide by the following 1 Within three (3) business days of moving to or returning to the Virgin Islands you must register in the Virgin Islands and keep your registration current in each jurisdiction in which you reside and in each jurisdiction where you are employed (inciuding self-employment non-compensated and volunteer activities). and in each jurisdiction where you are a student In the event there is 2 change in your name, employment, residence, temporary lodging information, vehicle information, or internet identifiers. you are required to appear in person at the Department of Justice not later than three (3) working days after such change. In the event that you move outside of the United States Virgin Islands, you must register your new address with the Department of Justice before you leave and you must also register in your new state not later than three (3) business days after arrival there if your new state has a registration requirement. In the event that you are traveling outside of the Virgin Islands your are to required to appear in person at the Department of Justice prior to your departure and provide your travel destination, dates of travel, places of arrival and departure. itinerary details. address. contact telephone information. and purpose of travel Depending on the type of sex offense for which you have been convicted, you are required to appear in person at the Department of Justice to verify your _—information and to take a current photograph, when —necessary, { ] every three (3) months [ ] every six (6) months (every year. Depending on the type of sex offense for which you have been convicted, you are required to appear in person at the Department of Justice to verify your information and to take a current photograph, when necessary. for a period of p 15 years [] 25years [ ] forlife. ailure to comply with these obligations subjects you to prosecution for failure to register or update your registration pursuant to a. Virgin Islands Code, Title 14, Section 1730, punishable by a fine not less than $3,000 nor more than $5,000, or imprisonment for not less than three months nor more than two years, or both; and ... b. Federal Law, 18 U.S.C. Section 2250, punishable by up to 10 years of imprisonment. Be Reminded that 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 registration 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 YOUR NEXT ReGisTRATION pate: ///Q10 A G dolfP EFTA00315045