CID Report: 0263-04-CID259-80295

SUSPENSE DATE (YYYYMMDD)
COMMANDER'S REPORT OF DISCIPLINARY OR ADMINISTRATIVE ACTION •
For use of this form, see AR 190-45; the proponent agency is Office of the Provost Marshal General •
PRIVACY ACT STATEMENT
AUTHORITY:0Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated NOvember 22, 1943 (SSN).
PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified.
ROUTINE. USES:0Your social security number is used as an additiOnal/aiternate means of identification to facilitate filing and retrieval.

DISCLOSURE:0Disclosure of your social security number is voluntary.
1. THRU -2. TO0. 3. FROM USACRC. 0 WA:news OFFICeR.
40.10 610 STReer 1 lilt oA 1314 Coo) rr BELLXJ/R vi4 xao...5-sgs *- 461+
vi-Po 0 2
4. USACRC CONTROL NUMBER 5. MP REPORT NUMBER 6. SUB-INSTALLATION IDENTIFIER
oacd- octcoA57- 80.115
The first Lieutenant Colonel in the chain of command is responsible and accountable for completing DA Form 4833 with support documentation (copies of Article 15s, court-martial orders, reprimands, etc) for all USACIDC investigations. The unit and brigade commander or their equivalent will also receive a copy of the DA Form 4833 for all USACIDC investigations.
Company, troop, and battery level commander's are responsible and accountable for completing DA Form 4833 with supporting documentation in all cases
investigated by MPI, civilian detectives employed by the Department of the Army, and the PMO. Accurate and complete DA 4833 disposition reports are
required-to meet installation, command, HQDA, DOD, and federal statutory reporting requirements. The data is used to identify crime trends, establish command
programs in law enforcement and other activities, and to ensure that resources are made available to support commanders who must address issues of soldier
and family member indiscipline.
In court-martial cases, a conviction of an offense at court-martial may be for a different, or lesser included offense. LList the offense for which the individual was
convicted at court-martial in'the remarks section.

Block 5. Provost Marshals must enter the Military Police Report number for all cases referred to commanders.
Block 8. This block is used to enter report number from a civilian laW enforcement agency police report. Other information on the civilian law enforcement
agency (e.g. civilian law enforcement agency address) may be entered in the remarks section.

7 k 1 tA • UBJECT Last First Ml) 0. D0BIRTH (YYYYMMDD)
_ 11b. DATE OF OFFENSE(s)
11a. OFFENSE(s) 11c. ACTION TAKEN 11d. IF NO ACTION TAKEN, EXPLAIN:
(YYYYMMDD)
YES 1110NO Er
114G4ZAUlagto 45.14t1ll— (.3e19CIVOY
YES0NO
Lry.A4tottL,Teeicrvitear A0041010? .
YES D NO

12. ACTION TAKEN (check all that apply)
• Subject was advised that although no action was taken, the report would be retained in Army records and.hat requests for amendment,
correction, or expungement may be submitted IAW AR 190-45 (MP Reports) or AR 1,95-2 (CID Reports).
.„

a. NON-ADVERSE PERSONNEL ACTION REFERRAL: REFERRED TO (Check appropriate blocks) DATE REFERRED (YYYYMMDD),.. DATE RESPONDED (YYYYMMDD) F = FAMILY ADVOCACY D = ORIJCl/A1COHOI ABUSE
S = SPECIAL REFERRAL
__E_SIUAL OPPORTUNITY

=0
L = LEGAL OFFICE
M = MENTAL HEALTH
R = RELIEF AGENCY
.

b. ADVERSE PERSONNEL ACTION:0
REPRIMAND0ORAL0WRITTEN0.
FILED:0LOCALLY0OMPF

—
0LETTER OF CONCERN/COUNSELING
ADVERSE OER/NCOER COMMENT
0RELIEF FOR CAUSE OER/NCOER
SUSPENDED SECURITY CLEARANCE OR OTHER ADVERSE ACTION REGARDING SECURITY CLEARANCE
DISCHARGE PURSUANT TO AR 635-200 (ENLISTED)/AR 600-8-24 (OFFICER)
Regulation0 Chapter0.0Characterization0 Discharge Date

c. NONJUDICIAL PUNISHMENT (Article 15, UCMJ) (ATTACH COPY OF ARTICLE 15)
SUMMARIZED _ FIELD GRADE0 GCMCA IMPOSED
COMPANY GRADE GENERAL OFFICER IMPOSED

ri9/0
0d. JUDICIAL (If subject was tried by court -ma " ttach a copy of the court-martial order giving findings and sentences.)
SUMMARY COURT MARTIAL ENERAL COURT-MARTIAL

_
SPECIAL COURT-MARTIAL CIVILIAN OR MAGISTRATE CRIMINAL COURT

DA FORM 4833, JUN 2004 DA FORM 4833, Dec 1998, IS OBSOLETE Page 1 of 2
APD 9V1.000
DO D DOAC I D10734

13.
JUDICIAL FINDINGS

14.
RESULTANT SENTENCES, PUNISHMENTS, OR ADMINISTRATIVE ACTION

a.
REPRIMAND b. ADMONITION (1) ORAL0(2) IN WRITING

c.
DETENTION d. FORFEITURE e. FINED0$0/0MONTHS

_
'TY DISMISSED
7,4OTN01 GUILTY OTHER (For example, guilty of a lesser included offense. Explain in Remarks.)

_
f. REDUCED FROM0TO0 g. EXTRA DUTY FOR0DAYS0h. RESTRICTED FOR0DAYS
_
i. CORRECTIONAL CUSTODY FOR0DAYS0j. CONFINED0YEARS0MONTHS
_
k. SEPARATION:0PUNITIVE DISCHARGE0OTHER0 '
_
Type0 Chapter:0 Characterization:0 Effective Date:
•
I. OTHER (For example, suspension of driving privileges. Explain in Remarks.)
15. REMARKS0•
?TS
FOOPO kfar 6URS'y rtii.Z /Mem G.ex.eizAt-e4}P
16a. TYPED NAME Ai D RADE OF GAMMArNefttlel-OF-FtCER-
_
16c. DATE OF REPORT (YYYYMMDD).
‘26,C2-5 OW0
16d. AKO ACCOUNT E-MAIL ADDRE
1 US . 4Why MIL-
DA FORM 4833, JUN 2004 Page 2 of 2
APD 9V1.000

DODDOACID10735

DEPARTMENT OF THE ARMY
3th MILITARY POLICE GROUP (CID)
78th MILITARY POLICE DETACHMENT (CID) (FWD)
UNITED STATES ARMY CRIMINAL INVESTIGATION COMMAND
BAGHDAD, IRAQ
APO AE 09342

27 Oct 2004CIMPR-FR
MEMORANDUM FOR SEE DISTRIBUTION
SUBJECT: CID REPORT OF INVESTIGATION — FINAL (C)/SSI - 0263-04-CID259-80295— /5C1/5Y2E
1. DATES/TIMES/LOCATIONS OF OCCURRENCES: 8 AUG 2004/1500 HRS — 8 AUG 2004/ 2400 HRS; DETAINEE CELL, FOB HEAD HUNTER, BAGHDAD, IZ, APO AE 09342
DATE/TIME REPORTED: 10 AUG 2004, 1000 HRS
INVESTIGATEL• A 1111 SAL SA
SUBJECT: 1.LT.
; WHITE; 1/9 — CAVALRY BATTALION, FOB HEADHUNTER, APO AE 09342; FC [AGGRAVATED ASSAULT] [CRUELTY AND
IZ, -
MALTREATMENT]

•INTERNMENT SERIAL NUMBER
VICTIM: 1.L
M; WHITE; XZ; DATE OF
(ISN):L
CAPT : 8 AUG 04; (NFI) [AGGRAVATED ASSAULT] [CRUELTY AND
MALTREATMENT]

INVESTIGATIVE SUMMARY:
This investigation was initiated upon receipt of Serious Incident Report CD-08AUG04-19C­
058011110rdated 9 Aug 04 from Headquarters, 3" I Brigade, 1 s` Cavalry Division, Baghdad, IZ, APO AE 09348, detailing Lad been assaulted by 111111111while he was detained at FOB Head Hunter, Baghda , IZ.
Investigation established probably cause to believe Lommitted the offenses of
Aggravated Assault, and Cruelty and Maltreatment when Llammed
noshead, which was covered with a sandbag at the time, into the side of a detainee cell
w Ile escorting him to the detainee cells after he was captured.

STATUTES :
Article 128, UCMJ: Aggravated Assault
Article 93, UCMJ: Cruelty and Maltreatment
FOR OFFICIAL USE ONLY
LAW ENFORCEMENT SENSITIVE

114 I 111-,-

0263-04-CI D259-80295
EXHIBITS/SUBSTANTIATION:
ATTACHED:
1. Agent's Investigative Report (AIR) of SA 1111 20 Oct 04, detailing the Basis for Investi atio i • rec i t of SIR CD-08AUG04-19C-058 0coordination with SJA• interviews
, coor • oration0int an
crime scene examination; coordination with interview of
recei t of Memorandum of Transmittal 0 0146-04-C1:D789• coordinations with

, and SJA• interview rime Records Center ame ec o 0interviews o0and0coordination with SJA and
2.
Serious Incident Report (SIR) CD-08AUG04-19C-05811111111111 9 Aug 04, detailingMinallegations of abuse.

3.
Photographic Packet, containing (6) digital photographs depicting the injuries
had when he arrived at FOB Grey Wolf, Baghdad, Iraq, after being transported there fro

L
IIIER. Headhunter (currently named FOB Independence). (USACRC, SJA and file copies only)
4.
Compact Disc 040263.259, containing (6) digital photographs, the originals of Exhibit 3.
(USACRC and file copies only).

5.
Detainee Health Assessment orm and Chronological Record of Medical Care (SF 600), 9 Aug 04, detailing0medical condition when he arrived at FOR Grey Wolf, after being transported t ere from FOB Headhunter.

6.
Correspondence written by M. 9 Aug 04, detailing the injuries she noted on ' 11111111 and allegations of abuse he reported when she interrogated him.

ement of ist), 12 Aug 04, detailing the interrogation he and conducted of also the allegations of abuse made by and the injuries he observed on during the interrogation.
8. Sworn Stat 12 Aug 04, detailing the medical examination he
conducted on on late 8 Aug 04, at FOB Grey Wolf, the injuries he observed on Mr Ma and allegations of abuse.
9.
Sworn Statement of an 24 Aug 04, detailing he observed 1111111.' strike an Iraqi Detainee.

10.
Sworn Statement of024 Aug 04, detailing he observed 11111111111, abuse the detainee UMW he (0was placing in to the detainee cell at FOB Headhunter.

2
FOR OFFICIAL USE ONLY A FORCEMENT SENSITIVE
DODDOACI D10737
0263-04-C1D259-80295
11. Sworn State 24 Aug 04, detailin his knowledge of the incidentbetween0and0when0was escorting0tothe detention cells at FOB Hea un er.
12. Crime Scene Sketch0by SA024 Aug 04, detailing the location of theincident between 0
and
13. Commanders Inquiry conducted by 0 1/9th CAV FOB Headhunter,9 Aug 04, detailing the results of an inquiry into the alleged abuse of
14. Sworn Statement of 111111111, 24 Aug 04, detailing his actions when the captured
detainee arrived at FOB Headhunter and that he did not observe 0

abuse anydetainees.
15. AIR of SA ON
, Baghdad Central Confinement Facility (BCCF), Abu Ghraib, IZ, 27Aug 04, detailing his o
ffices notification that ade allegation of abuse: medical
examination of
receipt of medical documentation in reference to
interview o and coordination's with Detainee In-Processing and the MagistrateCell at BCC
16. History and Physical Exam Form completed by 0, 25 Aug 04, detailing amedical examination he conducted on
17. Medical Narrative/Discharge Documentation from 31 St CSH, Baghdad, IZ, 24 Aug 04,
detailing0

eing treated for end-stage chronic renal failure, at the 3P 1 CSI' between
19 Aug 0 an0Aug 04.
18. Compact Disc 0146-04-CID789, containing digital photographic images of bruising on
various parts of
0
(USACIDC, SJA and file copies only)
19.
Detainee Dossier of Blindetailing biographical information of airmia ¦

20.
Detainee file of

21.
Sworn Statement of0

28 Sep 04, detailing he witnessed
and0
fall in the side of the detention cell together and he witnessed blood on the sandbag
at was covering0head, after they fell into the side of the detention cell.
22. Sketch pre are0
28 Sep 04, detailing the location where asand0fall into the side of the detention cell and his location whne he
withesse them all.
23. Sworn Statement of0
28 Sep 04, detailing the capture ofand the other Iraqis that were captured at the mortar site, and that he did not witness any injuries
on0detainee in white "man dress"), when he was captured.
3
FOR OFFICIAL USE ONLY
LAW ENFORCEM T SENSITIVE

0263-04-CI D259-80295

24.
Sworn Statement of0 28 Sep 04, detailing the capture and captureo and the other Iraqis at the mortar site, and that he did not observe and injures o at the time of his capture.

25.
Sworn Statement of 28 Sep 04, detailing the capture of...and the other Iraqis at the mortar site

26.
Sworn Statement of 028 Sep 04, detailing the capture of NMand the other Ira is at the mortar site, and that he did not observe any injuries on the detainee in the man dress

27.
Sworn Statement of Me 3 Oct 04, detailing the capture ofillaand thew th0 when he

other Iraqis at the mortar site and that he did not observe any injuries on 0
was initially captured.

28.
Sworn Sta 3 Oct 04, detailing when he observed the detainee in the white didashi after he had been placed in the detention cell, he observed a cut over the detainee's eye.

29.
Sworn Statement of 015 Oct 04, detailing the capture of the man wearing a white gown0and the other Iraqis at the mortar site, and that he did not observe any injuries on the man in the white gown when he was initially captured.

30.
AIR of SA EMU 43rd MP DET (CID), Ft Hood, TX, 16 Se 04 detailing receipt of a Request for Assistance sent by this office to attem iit to interview0who was on R&R Leave; and coordinations with 0 egal Tinsel), and

110111111
NOT ATTACHED:
Maintained in original case file (Classified Secret).
(S/NOFORN) 31. TF 1-9 Patrol Debriefing Form (Extracted from Exhibit 12) of 11111
8 Aug 04.

The originals of Exhibits 1, 3, 7 through 12, 14, 15, 18, and 21 through 30 are forwarded with
USACRC copy of this report. The originals of Exhibits 2 4 (photographs contained on the
compact disc) and 6 are retained in the files of 0SJA, FOB Grey Wolf, Baghdad, IZ.
The originals of Exhibit 5 are retained in the files of t e 3 DE, 1 st CAV BN, Aid Station, FOB
Grey Wolf, Baghdad, IZ. The originals of Exhibit 13 are retained in the files of 1/9 th CAV BN,
FOB Independence, Baghdad, IZ. The originals of Exhibit 16 are retained in the files of the
390 MP BN, Detainee Aid Station, BCCF, Abu Ghraib, Iraq. The originals of Exhibit 17 are
retained in the files of the 31 st CSH, Baghdad, IZ. The original of Exhibit 19 retained in the files
of the Detainee In-Processing Section, BCCF, Abu Ghraib, IZ. The originals-of Exhibit 20 are
retained in the files of the Magistrate Cell, BCCF, Abu Ghraib, IZ.
4
FOR OFFICIAL USE ONLY

W ENFORCEMENT SENSITIVE

14 CIO
DODDOACI D10739
0263-04-C1D259-80295

STATUS: This is a Final (C) Report. This investigation was terminated in accordance with CIDR 195-1, paragraph 4-14 (a)(6), in that the Special Agent-in-Charge has determined that furtherance of the investigation would be of little or no value and that the leads remaining to be developed are not significant.
Remaining Leads: Interview0and identify and interview other soldiers who may have knowledge of the incident between 0and NNW
0
Report Prepared By: Report Approved By:
Special Agent0 Special Agent m
Distribution:
1-DIR, USACRC, 6010, 6th Street, Fort Belvoir, VA 22060-5506 (original) 1-Thru: CDR, 22nd MP BN (CID) (FWD), APO AE 09342 Thru: CDR, 3rd MP Group (CID)
To: CDR, USACIDC ATTN: CIOP-ZA, Fort Belvoir, VA 22060 1-CDR, ATTN: LTC01/9th CAV BN, FOB Independence, Baghdad, IZ, APO 1-PMO, MNF-I (e-mail only) 1-CID LNO, MNF-I, APO AE 09342 (e-mail only) 1-Office of the Staff Judge Advocate, ATTN: MAJ01 St CAV, Camp Victory, Iraq 1-File
b2.447‘

5
FOR OFFICIAL USE ONLY LAW ENFORCEMENT SENSITIVE
DODDOACI D10740
For Official Use Only
Law Enforcement Sensitive
80295

AGENT'S INVESTIGATION REPORT.0263-04-CID259-

CID Regulation 195-1.Page 1 of 7 Pages

Basis for Investigation: On 10 Aug 04, this office received Serious Incident Report (CD-08Aug 04-19C-058Ldquarters, 3 rd Brigade 1 st CAV DIV, Baghdad, Iraq, APO AE 09348, detailingL(Capture number: liravasassaulted while he was detained at
FOB Head Hunter, Baghda Iraq (IZ) by U.S. Forces. (See SIR and attachments for details)
About 2000, 11 Aug 04, SA Illicoordinated with CPT Staff Judge Advocate, Forward Operating Base (FO Lolf, Baghdad, IZ (FOBGW) who provided a color copy of the photographs taken of Linjuries. He also provided copies of a Detainee Health Asses nt form and F 600 (Chronological Record of Medical Care), both pertaining to Lmedical sc eeninLAug 04, when he arrived at
L.
FOBGW. The documentation detail- . . had when the medically screened, which was conducted by L , 3 BDE, 1 St CAV, Sur eon FOBGW.L .rovide a copy of a correspondence, • ated 9 Aug 04, Officer in Charge of Interro ations Delta Company, 312
i rtary me igence Battalion, FOBGW wrote in reference to legations of abuse and the injuries she noted on hen she interrogate im. (See Photo's, Detainee Health Assessment, SF 60 i or • etai s
About 0910, 12 Aug 04, Aug 04, she int o and stitches on t rviewedLrelate•L who related about 1100, 9 ad observed two black eyes was transferred from FOB
Headh stated Calvary controlled FOB Headhunter BBaghdad
state ad not been interrogated at her facility.

stated her questioning of Lin reference to his injuries was a part of rotocol to document previous injuries he may ave had before capture. She related Las not restrained while in his detention cell at FOBGW, and was not restrained during the interview she conducted.
AGENT'S COMMENT: During this investigation continuously presented herself as being unprofessional and uncooperative.
About 0920, 12 Aug 04, SA Waririnterviewed
Category 2, TiLOBGW, who related he translated for Lfor the
interrogation provided a sworn stateme LiLdetailed the allegations
made byLan the injuries he noticed on ody. (See Sworn
Statement for details.)
SA Special Agent Signat 78th MP DET Forward (CID) Baghdad, Iraq APO AE 09342 Date:.Exhibit:
CID Form 94 Oref/ FOR OFFICIAL USE ONLY
LAW ENFORCENE T SENSITIVE EXHIBIT 16-7)
DODDOACID10741 `37

For Official Use Only
Law Enforcement Sensitive

0263-04-CID259-80295

AGENT'S INVESTIGATION REPORT.
of 7 Pages

CID Regul- on 195-1

Agent's note.0e Internment Serial Number for 0 would
to interview without her present or in the immediate
not allow SA0
vicinity.

SA0with the assistance of0iinterviewed. stated he was arrested about 1500, 8 Aug 04. He stated after he was
11106111 1
0 in both eyes, in the back, on the right shoulder, struck twice in the
captured he was struc placed over his
stomach once in th chest, and once on the left shoulder with fi 0ag stated he was also
elated he was struck with fists and kicked. 0
head.0
struck on his left eyebrow with the mu le of a rifle, but the soldier apologized to him in English because it was an accident. related he received stitches from a doctor at FOB tated he was only pushed when he was put
Headhunter for his injury to is eye.0
into his cell and never struck.
0

w
Agent's Note:o uld not allow SA -to interview without her present. 0related this was not the story provided to him during the intenoga ion. u ama Airport is FOB Headhunter.
ho rendered a sworn
About 1045, 12 Aug 04, SA 1111 interviewed0 statement detailing his medical screening examin tion of 0when he arrived at FOB Grey Wolf on 9 Aug 04. He relat he asked 0• ough a mterpreter how he
sustained the injuries he had and 0replied that unknown American soldiers beat him after he was captured. (See Sworn tatement for details)
, D
About 1618, 24 Aug 04, SAIIIIcmterviewed0
Company, 215 Forward Support Batt ion, FOB Headhunter, IZ, who provided a sworn

0a Iraqi detainee. (See
statement wherein he detailed how he observed
Sworn Statement for details)

,A
About 1700, 24 Aug 04, SA0111111interviewed
DE, OB Headhunter, ed a sworn statement detailing heCo, 215th FSB0
witnesse0abuse the detainee he was placing in the detainee cells at FOB Hea hunter. ( ee Sworn Statement for etai
Abou 1700, 24 Aug 04, SA0coordinated with Dr. (CPT), . Headquarters and Headquarters Company, 119 th CAV, FOB Headhunter, IZ, who re ate e had stitched a prisoner's head around the n tee out 1400, 8 Aug 04. Dr. stated the prisoner was number 1111.1 Dr. 0related he did not ask how the oner received the injury. Dr. 1111. could not relate w o the interpreter was that assisted
78 th MP DET Forward (CID) Special Baghdad, Iraq APO AE 09342
ii1111111111 11,

Agen•11111

Date: Exhibit:

a9
11111111111111ESC Form 94 R OFFICIAL US.?EC2oN-

CID.QLI-

LAW ENFORC SENSITIVE

EXHIBIT 1 ( -7)
I210 N4 re....
DODDOACID10742
For Official Use Only
Law Enforcement Sensitive
AGENT'S INVESTIGATION REPORT.0263-04-CID259-80295

.

CID Regulation 195-1 Page 3 of 7 Pages
him. Dr.0stated prisoners requiring medical attention were brought directly to the aid station for treatment.
Agent's Not0coordinated0D0 medical treatment records. Dr.0relate , HHC, 1/9th CAV, FOB Headhunter, IZ, took the recor s or e -6 investigation into the alleged abuse.
About 1730, 24 Aug 04, SAM interviewed HHC, 1/9 CAV REGT, FOB Headhunter, IZ, who related the detainees arrived at the FOB HEADHUNTER in the left in the evening. 1.1111111. stated he knew a prisoner by ame o arrived on the morning of 8 Aug 04 and left that evening. related when ' ' was being loaded into the vehicle in the evening, e had lost s footing and fel e body portion of the M-4 a soldier was carrying slung around his neck and soldier. 'd not see which specific part of the weapon
face had hit, but did see an injury to the upper area of the left eye socket of/.
tated he had seen the stitches to the right eyebrow ofillIMMO but did not se any o er mjunes.ailMlarelated he had not seen any prisoners with facial bruising or other injuries before_. at FOB HEADHUNTER.
0
About 1858, 24 Aug 04, SA nterviewed HHC, 1/9th CAV, FOB Headhunter, IZ provided a sworn statement detailing he did not directly witness abuse the detainee he was escorting into the detention cells as he had his back to and the detainee at the time. He related after he heard a loud noise and turned aroun and saw the detainee0had was on the ground he thought
MM. had done something to the detainee, but e id not witness anything. (See Sworn Statement for details)
About 1910, 24 Aug 04, S0this office, conducted a crime scene examination of the
Detainee Detention Facility on FOB eadhunter, IZ.
Characteristics of the Crime Scene: The Detainee Detention Facility (DDF) was located at Al Muthania Airport, Baghdad, IZ, APO AE 09348. The DDF was a 30 meter by 10 meter, white in color, wood and metal constructed building separated into three, 10 meter by 10 meter, holding cells with a mesh front door and screen. The door, of Holding Cell number three, was located on the north wall and was made out of metal-type bars. The west, south, and east walls were made out of wood-type material and painted white in color. The floor was made of wood-type material and so was the ceiling. The walls and ceiling were white in color. Cell one had a aluminum­type folding cot which ran along the west wall and was adjacent to the northwest corner of the cell. The metal doors to the cells were secured with a key lock. The entire detainee center was
SA 78th MP DET Forward (CID)
Special Agen Baghdad,. Iraq APO AE 09342
S Date:.Exhibit:

i 20 00" aV
CID Form 94.FOR OFFICIAL USE ONLY

LAW EE RCEMENT SENSITIVE

EXHIB I T / 0-7)

La 1,4
DODDOACI D10743
/o
For Official Use Only
Law Enforcement Sensitive
-

AGENT'S INVESTIGATION REPORT.0263-04-CID25980295

CID Regulation 195-1 Page 4 of 7 Pages

a 40-meter by 100-meter area. There was triple concertina around the outside of the Detention Center with a controlled entrance on the west side and a entrance on the east.
Condition of the Scene: Holding cell was quite tidy. The furniture was upright.
Environmental Conditions: The outdoor temperature was approximately 92 degrees Fahrenheit. The sky was clear and there was no moisture present on the ground.
Factors Pertinent to Entry/Exit: Entry to the Detention Cell 1 could be achieved through the north door. Entry to the Detainee Cell could be achieved from the west or east side of the Detention Facility.
Scene Documentation: SA IIIIIIIrrepared crime scene sketches and exposed crime scene photographs utilizing a Samsung, Digimax Digital Camera. The photographs were subsequently incorporated into a photographic packet. (See Crime Scene Sketches and Photographic Packet for details)
Search for Latent Impressions: Due to the delay in reporting, a search for latent impressions was not conducted.
Collection of Crime Scene Evidence: No evidence was collected.
Agent's Note: A search beyond the scene was not conducted due to the delay in reporting of the
incident.

About 2030, 24 Aug 04, SALbriefed
CommLth CAV, FOB Headhunter, IZ, on all aspects of this investigation to date.
provided a copy of a Commander's Inquiry, dated 9 Aug 04, concerning the
abuse of detainee L(See Commander's Inquiry for details)

About 2240, 24 Aug 04, SALinterviewedL CSM,
1/9th CAV, FOB Headhunter, IZ, who provided a sworn statement detailing he did not witness
or any other soldier abuse any of the detainees that were arrested on the day in
question. ee Sworn Statement for details)

About 1700, 30 Aug 04, this office received Memorandum of Transmittal (MOT) 0146-04-
CID789, from the Prisoner Interview/Interro ation Team, Baghdad Central Confinement Facility
(BCCF), Abu Ghraib, IZ, which indicated

SA. 78th MP DET Forward (CID)
Special Agent.- Baghdad, Iraq APO AE 09342
Sign.•.Date:.Exhibit:

Oa oct-ei
CID Form 94.OFFICIAL USE ONLY
LAW ENFOR EMENT SENSITIVE

EXHIBIT rt-7 )
DODDOACI D10744
For Official Use Only
Law. Enforcement Sensitive
AGENT' S INVESTIGATION REPORT0 0263-04-CID259-80295

0
CID Regulation 195-1 Page 5 of 7. Pages Lreported he was abused prior to being transferred to BCCF. (See AIR of SAUlliand supporting documents for details)
AGENT'S COMMENT: This office had received notification on this incident and initiated this Report of Investigation, prior to L• eing transferred to BCCF, where the aforementioned MOT originat
About 0920, 22 Sep 04, SA coordinated with MEM , who related while he was on R&R Leave, he obtained a civilian lawyer who directed him not to discuss anything with CID. Lrelated his lawyer was Hemphill Legal Services, The Lyric Center, 440 Louisiana, Suite 2120, Houston„ phone number: (713) 222-
About 1530, 23 Sep 04, SAMIIMIlbriefedill11111111111r Chief of Military Justice, 1 Cav SJA, Camp Victory, IZ, on all aspects of this investi ation to date. Lpined there was sufficient probable cause to believe Lcommitted ie o nses o Aggravated Assualt and Cruelty and Maltrea L.
AGENT'S COMMENT: Briefed this office wasgoing to interview the soldiers who initially capturedLIt was determined reportedly sustained injures due to resisting initial capture.
About 1019, 28 Sep 04, SA11111 interviewed 11111111111111111111111.1111111. HHC, 119th CAV, FOB Indepen ence (formally FOB Headhunter), IZ, who provided a sworn statement. Lstated when he was walking up to the holding cell area he witnessed bothLand the detainee he was escorting to the holding cells, fall into the side of the ho g cell, and after this he witnessed blood on the sand bag which was over the detainee's head. At the conclusion of the interview 1111111111111drafted a sketch depicting the location whenLd the detainee feel into the holding cell and his location when he witnesse em a . See Sworn Statement and sketch for details)
AGENT'S COMMENT: The name of FOB Headhunter was changed to FOB Independence.
About 1025, 28 Sep 04, SA M this office, interviewed HHC, 119th CAV, FOB Independence, IZ, who provided a sworn statement. related the only injured individual was the one that was shot. MIMI tated he did see a man wearing all white Lbut tE7Mrhad mud on his face. ( ee Sworn Statement for details.)
78th MP DET Forward (CID) Baghdad, Iraq APO AE 09342 -
Date:0 Exhibit:
e7et-05,
CID Form 94 FOR OFFICIAL USE ONLY

b
".011017
7ENT SENSITIVE

EXHIB / 01-7)
DODDOACID10745
For Official Use Only
Law Enforcement Sensitive
0263-04-CID259-80295

AGENT'S INVESTIGATION REPORT.

Page 6 of 7 Pa es

CID Regulation 195-1

About 1049, 28 Sep 04, SA0nterviewed
w
HHC, 1/9th CAV, FOB Independence, IZ, who pro ed a sworn statement. erve the man that was shot, but did not see any other injured Iraqi Detainees. related the Detainees had mud and dirt on them but he did not see any injuries.
(See Sworn Statement for details.)
p
About 1122, 28 Sep 04, SA 1111! interviewedniumimurHHC,
1/91 CAV, FOB Independence, ,0• ed a sworn statement etas ing e initial capture .0stated he did not observe any injuries on the
of the detainees at the mortar site when he was initially captured at the mortar site.. (See
detainee in the white dress, Sworn Statement for details
AGENT'S COMMENT: 11111111111was the only detainee captured in a didashi.
A Co,About 1212, 28 Sep 04, SAi 0interviewed0
on, FO Independence IZ, who provided a sworn statement.
215th Forward Support Batt
elated he initially captured0, and subsequently placed him on the related the only injuries he observed on any of the detainees was the mangroan•
with the gunshot wounds. (See Sworn Statement for details.)
Me ic,
About 1132, 3 Oct 04, SA interviewed
HHC, 1/9th CAV, FOB Indepligence, aL, who provided a sworn statement. 0stated
he took part in the initial capture of the • • uals who were at the mortar site, but he did not observe any injuries to the man0who was wearing the white didashi when he was initially captured. ee worn • tement for details)
H C, 1/9th
About 1222, 3 Oct 04, SA 0interviewed CAV, FOB Independence,flad, IZ, who rovided a sworn statement. related
arrived at FOB Independence he noticed he had
after the man in the white didashi 0a cut over his eye, after he had been p aced in the holding cell at the FOB. (See Sworn Statement for details)
im cords Center (CRC),
On 13 Oct 04, a query of the files maintained by the U.S. Armin CoAe 'which revealed no derogatory information pertaining to
— , HHC,
About 1440, 15 Oct 04, SAIIIII interviewed IIIIIIIIIIIIIIIIIIIIIIIIII
sworn stated he
1/9th0CAV, FOB Independence, IZ, who provided a swo statement. 0took part in the initial capture of the individuals who were at the mortar s'te but he id not
when he wasobserve any injuries to the man who was wearing the white gown 0min
Special Agent 78th MP DET Forward (CID) Baghdad, -Iraq-APO AE 09342 Date:.Exhibit:
D Form 94 c1- o9/ FOR OFFICIAL USE ONLY

LAW ENFORCEMENT SENSITIVE

EXHIBIT 7)

bibtk_
DODDOACID10746
For Official Use Only
Law Enforcement Sensitive
AGENT'S INVESTIGATION REPORT.0263-04-CID259-80295

.

CID Regulation 195-1 Page 7 of 7 Pages

initially captured, and when he saw him again before he was taken out of the vehicle that was
used to transport him . to FOB Independence. (See Sworn Statement for details)
About 1445, 15 Oct 04, SAM interviewedliMill'OB Independence Translator
Badge Numberillk New Baghdad, Sector 704, Street 16, House 19, Baghdad, 1Z.10111111/1111
was hired as a translator and works for Titan Corps, International Zone, Baghdad, Iraq, and has
worked at FOB Independence as a Translator for HHC, 1/9 th CAV, FOB Independence since 29
Apr 04. He related he only takes part in the missions the unit conducts and does not assist with
interpreting on the FOB. 111111/111 stated he was the translator who went out with the soldiers
the day the men were captured at the mortar site. He stated while he was on the mission he heard
shots fired, and he heard a soldier yelling for him, so he ran to where the soldier was and saw
four Iraqi men on the ground next to a mortar tube. He related a few minutes after that a couple
of soldiers brought another Iraqi man to the location, which apparently tried to escape. MI

41111111111stated one of the Iraqi men who was captured, and wearing a white didashi 4111111
MIMI" asked him why he was helping the Americans, and he said he told the man in the white didashi to shut-up and that he, the man in the white didashi was a criminal. 111111.1 stated he related he did not see any injuries on the man that was wearin the white didashi, and did not see any of the captured men resist after they were captured. 0stated he did not see any of the soldiers who captured the Iraqi men that day at the mortar site abuse the captured men. MINIM related after the captured men were taken from the mortar site by soldiers back to the FOB, that was the last time he saw them.
About 1600, 16 Oct 04, SAM. briefed0 Chief of Military Justice,
Office of the Staff Judge Advocate, 1 CAV BDE, Camp Victory, Baghdad, IZ, on all aspects of
this investigation.0stated he agreed with the opine 0provided
this office, which was there was sufficient probable cause to believe 0committed
the offenses of Aggravated Assault and Cruelty and Maltreatment.

About 1908, 20 Oct 04, SA III,bri efed0 Commander, 1/9th CAV, FOB
Independence, Baghdad, IZ, on all aspects of this investigation. 111111111111111.111 related no
further assistance was needed from this office. 0 related he did not know at
this time what type of action would to be taken against 0.///LAST ENTRY///

SA 78th MP DET Forward (CID)
Special Agent,.Baghdad, Iraq APO AE 09342
Signature:.Date:.Exhibit:

,eo Oafa9
CID Form 94.FOR OFFICIAL USE ONLY
LA EN.

NT SENSITIVE

EXHIBIT I (7-7)
1%1 DODDOACID10747
EXHIBIT(s)
Page(s) JD referred to
J4--46 64 6-)t Oo'{uOe tL
DODDOACI D10748

Exhibit

Page(s)L withheld

Exemption(s)L

Pertains toL
DODDOACI D10749

DEPARTMENT OF THE ARMY
22b MILITARY POLICE BATTALION (CID)3RD MILITARY POLICE GROUP (CID) 'BAGHDAD, IRAQ ARAM 0934221 DEC 06
CIRF-ZA 28 Feb 06
MEMORANDUM FOR Director, US Army Crime Records Center, USACIDC, ATTN: CICR-CR, 6010 6th Street, Fort Belvior, VA 22060-5585
SUBJECT: CID Report of Investigation
1. Enclosed is a copy of CM Report of Investigation 0263-04-CID259.
One classified
document was extracted from the file and placed in a separate envelope, which is enclosed (seeROI for details). Exhibits 4 and 18 are located on one compact disk, which is also enclosed.
2. Point of contact is the undersigned at DSN (318) 822UP
Encl
1111111111p
1-ROI 0263-04-.
CID259
MSG, USA
1- compact dish Operations Sergeant1- unattachedVlassified exhibit
eta speed x 4x compatible
-
Product Support: 1-800-425-0049
DODDOACIDa5975

0 rxt 1-a14-700z59-10tvir
02 63.-04 -C1D259 -80295
. T1PTAThT1117 LTV A T 11.7 A 00120 fill. g7:71.77,
3))(2)-2
Datcfrime ally DV 1/ iv
Chief Complaint '0 -
. , —
History,.f tIllness AffVAMIEi .0YEgr1
FX4N1irr eraggrAW 11AFAMP701M951Mrir ..x.. 40, „121.e7WAINTIAMMWAWK.141Irfc,MWYJEKIPTIMMIP7

__..NWOILMINFANVO4EMERW/17WEINWPAP_ WAVr
lalifto7 -LI)(2)-2

6'
/A

Past Surgical History 0
Medications
Allergies 0 Social Hx: Tobacco (Y))packs per day ETCH (YIN Drugs (Y)61) 0
Immunization History 4;i2iPor Explain 0

Review of Systems (circle all that apply):
HEENT lice, vision problems,Eeanng prob lem A

, nasal allergies, d2tal problems, other0 CV "1'44i14067 .onary artery thsease, other it44--PULM tstlun9other Ofria:tedkaft
0ronic cough, sputum production, kCET----hx a GI hea­
nausea, vorm n diarrther, 79renux, gas 'c u cer ood ' stools, intestinal parasites, otli,tr
GU STDs0ey stone . .0-0,7 e .4.,44474 MUSCULOSKELETAL chronic bac pain, elbow, shoulder, 0e,0e, other' NEURO stroke, seizures, headaches, muscle weakness her DERM rashes, lesions, scars, tattoos, other ENDOCRINE diabetes, other (1) PSYCH 90depression, anxiety, schizophrenia, bipolar d/o, homicidal or suicidal ideation, other INFECTIOUS DISEASE 0fever, night sweats, swollen lymph nodes, other io known TB, Hep B, Rep C,
VS0lit/Wt0 HR.0 BP 002 Sat0 Physical Exam: Normal 000Explain any (N) in detail. May continue on back of form if necessary GEN HEENT CV CHEST/LUNGS ABD EXT0 (1e) (14)SKIN0 (Y)MUSCULOSKELETAL0(N)0 NEURO0 (N)0 LABS
,.,
AS ,ISSME0h.¦.
awituriserg eIre e/M_IMP ‘ Iv A,Oilf-W.
PLAN: Recommended type ofconfin7d ( ormal ( 0) Solitary ( ) 0th explain0 Cleared for basic transfer procedu 0(N) if no, explain0 Infec n Co trot Pr uti • ns: n and ( ) C tact/Droplet ( Aoitniae0
•0_
b)(6)
DETAINEE # r3,2921.,0 Medical Screener 0
DOB0 'b)(6)

/40
GENDTIOF0FOR OFFICI b)(2)-2

LAW ENFORCEMENT SENSITIVE

EXHIBIT 46-r(
DODDOACID10751

02 6
•HEALTH RECORD CHRONOLOGICAL RECORD 01 .ED1CAL CARE
DATE SYMPTOMS. DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (SaM each entry)
,b)(2)-2
(b)(2)-2
# e.......g... , Itt

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PATIENT'S IDENTIHCATION (Use this space far Mechanical RECORDS

Mum) MAJWAIRED
AT.: PATIENT'S NAME (Last. Ow. Midis Initial) S X
(b)(6)
MI-Ain-maw I 4.) brUNWPI SI AIL'S RANK/ GRADE
I ..42r4f.e
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• SPONSOR'S NAME0-- -0•
72) 7 - - — /071 D EPA R T ./ BE FtV I C E SSNADENTIFICATION NO, DATE OF BIRTH
A, eb-064,16_0 14- /1C-M5- IVV_P, 6(020_
CHRONOLOGICAL RECORD OF MEDICAL CARE STANDARD FORM 600 inv. 5-84/ Prescribed by GSA and 'cum FIRMR (41 CFR). 201.43.506
FOR OFFICIAL USE ONLY LAW ENFORCEMENT SENSITIVE

EXHIBIT #5-o---.)
DODDOACI D10752
.26304-CID25980 2 95
(From a 9 AUG 04 e-mail from CW2 ags2x OMT) Sir,
According to detainee he received the cut over his right eye by accident when the soldiers went to Put him into the Vehicle. He hit his head on the muzzle of one of their weapons, the soldier apologized and detainee believed it was an accident
He received the bruise on his left shoulder and his back after he was restrained but before he
was moved from the site where he was caught He said the soldiers tied his hands behind his back and kicked him in the shoulder and back then moved him to the vehicle. He said two people hit him at this time an officer and a soldier who he could not identify. He believed one was an officer because he had a pistol in holster on his leg.
Detainee said his head was covered with a bag once he was in the vehicle and when the soldiers took him out of the vehicle he was nearly beat to death by multiple soldiers. He could not identify
them because his heed was coveted.
When I interrogated the detainee he had two black eyes and visible bruises on his shoulders and abdomen.
Let me know if you need anything else,
Ms
•
G
FOR OFFICIAL USE ONLY

EXHIBIT #
ENFORCEMENT SENSITIVE DODDOACID10753
0263-04 -CID25,9 -802,95Mby-oi*--cr-gz5Y-Vet,
SWORN STATEMENT
For use of this form. see AR 190-45: the proponent agency is Office of The Deputy Chief of Staff for Personnel.
LOCATION DATE0TIME WWILE NUMBER
Foe. Grey WOLF-/ 2 140604 10.' (its
SOCIAL SECURITY NUMBER0GRADE/STATUS

011.111111111111-1001110
-1 - n -i. - F013 Gr Wait: APO 1 AC
WANT TO MAKE THE FOLLOWTNa STATEMENT UNDER OATlii_

A6"0-1" li06 Ai-1130, IA(j O. T ute.4.4-w.+14, Ctinillill-fn ivvivorrri eff11111111111. Beare 1.45 to. 1n1")-kou4.--teeisekhni we wonted -in aoldr-esN oily 2,4 jor-¦e..s. on 42 t-eff 014 -ihe...ei4 eldi oskeri 1l t-rn.).5ic. It40 hot4 ha re,c el'oed -il4a. ivy jut-ieS 04 kis Anci ri kid teiltafe. he. PeteAleic Garsivi soles. adZIIIIIIe t.)as cal-ero/ (244c.1-6 S 411.10 iH t (LIP1-to re'Ce A hoc) Wis re St ftrre ST 1111.1.1115ej tile I:0 14 Wet, 16_ Cc1i el 6Atte 14:4 ri Ici- eye amr4-11.te_lii± ki% ()EC-1 .-Ptuatit tve c444 • tar V e eteo) cud "li
Kk ...C.E0 p 1:1.,,i-res On ink /di eie Ag PRatilthor 4 (J e:1. At ita AIVAP All 1721 e ellAP .N.old let-ri lle ci4 d 414.e. 5601/) fel, apOio",.Zer) /%1 en1,1-1, .M111111so.k) 4e. te-taSoleao lo /1/1.)7ZetA4 Asepr,sf 71;sa fol inn 4,odily a.AWf to 4e•-e Ac' tecekivt.) 1414 lorie-c. 11111•111 said His • 00....c CAI J I-..)-p A et.i4A 14 aid ikni See Ls. )11,0- Str-I.)Ck 1-¦1, WI
lip
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1 tei‘
EXHIBIT INITIALS OF PERSON MAKING STATEMENT
ADDITIONAL PAGES MUST CONTAIN THE HEADING 'STATEMENT OF TAKEN AT DATED CONTINUED."
THE BOTTOM OF EACH ADDI77 e AL. PAG ST B KING THE ST NT AND BE INITIALED AS 'PAGE OF PA E efivi:itL• _ • E BACK OF P 41 ,V0• ;
1'

LINED OUT, AND THE STATEM: T W 13 R COPY
f .
•
04•
1'1 A FORM el o•-t SEDES DA FORM 2823, 1 JAN 68, WHICH WILL BE USED.
DODDOACID10754
02. CID259 -80295,
i0215"
FILE NUMBER: a 4.41.--0--4:4M-TAKEN AT F613 Grey 4/13F DATED Z4066 41 CONTINUED:
STATEMENT OF STATEMENT (Continued)

AFFIDAVIT
HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT
WHICH BEGINS ON PAG AND E D E21 FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE BY ME. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED 'THE BOTTOM OF EACH PAGE CONTAINING THE.
THE STATEMENT IS TRUE.
STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLUENCE, OR UNLAWFUL INDUCEMENT.
igna ure o a
WITNESSES:
Subscribed and sworn to before me, a person authprtzed by law to administer oaths, this / 2- day of frUer , 20 09 at
ORGANIZATION OR. ADDRESS
INITIALS OF PE
PAGE Z OF0PAGES

DODDOA
_gr
az05-0f--ai0 e5/-itre'
SWORN STATEMENT
For use of 0 )rm, see AR 19045; the proponent agency is 0CSOPS
PRIVACY ACT STATEMENT

°2-6-3=1:rr=rnri59iro-szts-
Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22. 1943
AUTHORITY: (WW1. To provide commanders and law enforcement officials with means by which information may be accurately
PRINCIPAL PURPOSE: Your social security number Is used as en additional/alternate means of identification to facilitate, tiling and retrieval.
ROUTINE USES: Disclosure of your social security number is voluntary.
DISCLOSURE:
2. DATE
4. FILE NUMBER1. LOCATION0•
0
ORGAN TIO R ADDRESS
Nat-

WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
111L4-0 -tx fact 10-7 4 )2_Gl-v./I/v(4 Vtd w.Kees J1141. 1.4/1 be hill.IP foe tqed
0 . 1=-1.4
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y, Tr, 47) f pver 1 as co n its I saw aizi-.4.0e
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44 I .i ryrAq?r. A A alive duly U5.i Tata who Ikry ,:u net Os
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1DDMONAL PAGES MUST CONTA HE HEAD STAT ME TAKEN AT DATED. "
P ,
HE BOTTOM OF EACH ADDITIONA yi PgiVTIPAIMIGYKIN. G THE STAMM. RUST BE BE INDICATED. .!
DODDOACID10756—""'
•

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: IF THIS PAGE IS NOT NEEDED, PLEASE PROCEED 6Q2FtlAj. tixtf guts
•USETI.IliPAGEIF NEEDED:
AKEN AT .14, cv-0-6W DATED 1 2-
STATEMENT
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: • ..•
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DODDOACI D10757 33

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• 4iAtA::44.7"., 44' 13 , a , E), „

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STATEMENT 0. TAKEN AT "0,0 tiro-tz•eff 8•11,0*/fear DATED 11Jour
9. STATEMENT (Continued!

AFFIDAVIT
HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT
ON PAGE 1. AND ENDS N PAGE . I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE
BY ME. THE STATEMENT IS TRUE. I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE
, OUT

4
CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT Rf" •"

THREAT OF PUNISHMENT. AND WITHOUT COERCION. UNLAWFUL
WITNESSES: Subscribed and sworn to before me. a person *Inherited by law to
administer oaths, WS / Z. day of f
ORGANIZATION OR ADDRESS
e0?
htulAr.i.a.i --
ORGANIZATION OR ADD utheidtio re. AdMInliter 03031: -..
INITIALS Op PERSON MAKIN
Ire
S3
• =,
•
SWORN STATEMENT
For use of tb -mi. see AR 19045. the Proponent agency isf:SOPS

PRIVACY ACT STATEMENT Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943 (SSN).
AUTHORITY:
To provide commanders and jaw enforcement effiCials with means by which information may be accurately
PRINCIPAL PURPOSE:
Your social security number is used as an additional/alternate means of Identification to facilitate. filing and retrieval,
ROUTINE USES:
Disclosure of your social security number is volimtarv.
DISCLOSURE:
2: DATE 3. TIME 4. FILE NUMBER1. LOCATION
¦19..f,Y clS / fr C
FOB. HEM) kV Arralz-
NAME, FIRST. NAME, MIDDLE NAME
9. ORGAN
Fel.fr
, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
__04 hie .c110,4) tap Ii: //1 /AA /e;)eP 7 : pdk-4,,,ee3 &sr ,141 13.ne IPA etAtO ?(-Ae 9 4 Ay
n
Y
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10. EXHIBIT 11.fF PERSON MA
PAGES
PAGE 1 OF. "f

DATED
DDMONAL PAGES MUST CONTAIN THE HEADING .
TIE BOTTOM OF EACH ADDITIONAL PAGE MU •as.G'.• 4UST BE BE INDICATED.' ":: • •
• .flos alf% „ **".•
04 -C10259 -80295,
•-.•. .44 v.
•
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" 4/14: USE THIIPAGE1P NEEDED: IF THIS PAGE IS NOT NEEDED, PLEASE PROCEED TO FINAL PAGE OF THIS FORM,
TAKEN . AT .1:& Ftem, IwkITET DATED V4 406 041
sTkiiniEkro
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•. PAGE 2; DA FORM 2823..
4
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tr'.•. beta ¦Ike e s
)4.• In €.10.4 fa; tokec 4 01.e .16,"see dit)
A F'roA. IA/
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a Do hot, cult. a cP.tea 11-sta:fewatti .:' At fro , "/ 1-; Sfizetie.Ae,274
AFFIDAVIT
I,f , HAVE READ OR HAVE . HAD READ TO ME THIS STATEMENT WHICH BEGIN 0f GE.3_,. I FULLY UNDERSTAND THE CONTENTS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE I HAVE INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL INFLU CE..OR UNLAWFUL INDUCEMENT.
•
Subscribed and sworn to before me, • person authorized by law to
administer Oaths dsy of 4,5 el 4,1
st
ORGANIZATION OR ADDRESS
ORGANIZATION OR ADORES
Aar
_ 4 -LiDzbo.

SWORN STATEMENT..2 6 3 .
For use of th( nn, see AR 19045; the proponent agency isf:SOPS
PRIVACY ACT STATEMENT Tide 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943 (SS"
UTHORITY:
To provide commanders end law enforcement officials with means by which information may be accurately
UNCIPAL PURPOSE:
your social security number is used as en additional/altemate means of identification to facilitate. filing and retrieval.
)UTINE USES: Disclosure of your social security number IS yoluntarY.

:SCLOSURE:
2. DATE 4. FILE NUMBER
LOCATION
24 Auj 0
SSN GRADE/STAT S
• ° • e; e -
.9 , 0.
f• WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
irt,rhhieS )tiler
1_,Marg
a.liftniFINFMIN6 rlif

ViOVS)
•
14 •/// e.
). EXHIBIT 11. IN N MAKING STATEMENT

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