Military Police Investigative Report in to allegations of a soldier in Afghanistan pointing a gun at the head of a restrained detainee. The soldier offered a statement in which he states 1) the gun was a BB gun and not his service weapon; and 2) his Unit was working with Special Forces who directed him to maintain a weapon on the detainee at all times. The report was generated after a photograph of the soldier surfaced during a domestic police incident depicting him pointing what appears to be a pistol at an unidentified, hooded detainee whose hands were tied. No disposition of the matter is indicated
MILITARY POLICE REPORT For use of this form, see AR 190-45; the proponent agency is ODCSOPS PRIVACY ACT STATEMENT AUTHORITY: '_Title 10 United States Code Section 301 Title 5 United States Code Section 2951 Executive Order 9397 dated Nov 22, 1943(SSN) PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified. ROUTINE USES:_Your Social Security Number is used as an additional/altemate means of identification to facilitate filing and retrieval. DISCLOSURE:_Disclosure of your Social Security Number is voluntary. MILITARY POLICE REPORT NUMBER DATE( YYYY/MM/DD) ORI NUMBER USACRC CONTROL NUMBER 01101-2004-MPC552 2004/05/18 NY02200DM THRU: TO: COMMANDER FROM: ATTN: DIRECTORATE OF 2-14 IN C CO EMERGENCY SERVICES FORT DRUM,NY US 13602 P10715 MT BELVEDERE BLVD FORT DRUM, NY US 13602 Section I -Administration 1. REPORT TYPE: 3. EVALUATION: 4c. COMPLAINT RECEIVED' 5a. CLEARANCE REASON: 5b. EXCEPTIONAL CLEARANCE _ — BY: DATE: (YYYY/MM/DD): Information X Founded A Death of Offender _ — Unfounded In person B Prosecution Declined 2004/05/18 _ — X Military Offense 911 C Extradition Declined 4a. COMPLAINT — CB 7. INVOLVEMENT: X Criminal D Victim Refused To DATE: X Complaint X E Juvenile, No Custody — — (YYYY/MM/DD): Hate _ Domestic Mail U Unfounded — _ Death Gang — Radio X X Apprehension — 2004/05/17 — Trainee ExtremistCrime Stoppers Alarm 2. STATUS: 4b. COMPLAINT 6a. MP ACTION: 6b. DATE TIME:2(24hr.): Other (Specify): REFERRED: X Initial _...._ — MPI _ Traffic (YYYY/MM/DD): Supplemental 2315 X CID Other (Specify) Cdr's Action 2Civil Authorities 2004/05/17 — Section II - Offense la. OFFENSE NO. lb. SUBJECT NO. lc. VICTIM NO. ld. NIBRS le. 1f. SAME OFFENSE DATA FOR ALL INVOLVEMENT: INVOLVEMENT: LOCATION CODE: x Attempted OFFENSE CODES: _1 1 1 10 2Completed 0Yes2X_No (See 3975-1) 1g. OFFENSE lh. OFFENSE DESCRIPTION(s): li. OFFENSE LOCATION ADDRESS: CODE(s): AGGRAVATED ASSAULT ARTICLE 128 UCMJ (OFF POST) 5C1N UNKNOWN ADDRESS IZ 2a. BEGIN DATE: (YYYY/MM/DD): 3. TYPE OF CRIMINAL ACTIVITY 4. OFFENSE STATUTORY BASIS: 5. OFFENDER USED 2003/08/01 (Check Up To Three): (Check Up To Three) A UCMJ _ B Buying/Receiving B Non-Criminal Fatality _ A Alcohol 2b. BEGIN TIME (24hr.): _C Cultivating/Manufacturing/Publishing C State C Computer Equipment 0001 _ — D Distributing/Selling D Local D Drugs/Narcotics E Exploiting Children _ E Foreign X N Not Applicable2c. END DATE: (YYYY/MM/DD): — _ 0 Operating/Promoting/Assistin g F Federal, Non-UCMJ 2004/03/31 _ P Possessing/Concealing T Transporting/Importing2d. END TIME: (24hr.): — U Using/Consuming 2359 NATIONAL INCIDENT BASED REPORTING SYSTEM (NIBRS) LOCATION CODES 01 Air/Bus/Train Terminal210 Field/Woods/Training Area219 Rental/Storage Facility 02 Bank/Credit Union2 11 Government/Public Building220 Residence/Quarters/Barracks/BEQ/BOQ 03 Bar/Officer/NCO Club212 Grocery Store/Commissary221 Restaurant/Dining Facility . 04 Church/Synagogue/Temple213 Highway/Road/Alley/Street222 School/College 05 Commercial Office Building214 Hotel/MoteINAQNEQ/TLQ223 Service/Gas Station2 0 1,) Ii ko .; 06 Construction Site2 15 Jail/Prison/Corrections Facility224 Specialty Store/Concessionare 07 Convenience Store/Shoppette216 Lake/Waterway/Ocean225 Child Care Facility/Home Day Carle 08 Dept/Discount Store/Exchange217 Liquor/Store/Class VI226 Recreation Area/Park 09 Drug Stor/Hospital/Clinic218 Motor PooVParking Lot/Garage227 Training Center/Service School 228 On Board Ship DA FORM 3975, JUNE 2001 01101-2004-MPC552 DA FORM 3975, MAY 88, IS OBSOLETE Page 1 of 6 Pages 6. TYPE OF WEAPON/FORCE. Check up to three and indicate in the second block next to the item whether: F -Fully Automatic S - Semi-Automatic M - Manual 0U - Unknown 11 Firearm(Unk Type) 35 Motor Vehicle0I0I0I090 Other(Specify) 12 Handgun 50 Poison 13 Rifle 60 Explosives0 99 None 14 Shotgun 65 Fire/Incendiary 7. NUMBER OF PREMISES ENTERED 40 Personal Weapons 70 Narcotics/Drugs (For Burglary/Housebreaking only) 20 Knife/Cutting Instrument 85 Asphyxiation 30 Blunt Object 95 Unknown Forcible Entry0ElNo Forcible Entry 8. AGGRAVATED ASSAULT/HOMICIDE CIRCUMSTANCES (Check up to two) 9. ADDITIONAL JUSTIFIABLE HOMICIDE CIRCUMSTANCES 1 Argument 20 Criminal Killed By Private Citizen A Criminal attacked police officer and that police officer _ 2 Assault on Law Officer 21 Criminal Killed By Law Enforcement killed the criminal _ 3 Drug Dealing 30 Child Playing With Weapon B Criminal attacked police officer and was killed by -4 Gangland _ 31 Gun Cleaning Accident another police officer 5 Juvenile Gang 32 Hunting Accident C Criminal attacked civilian - ,__ 6 Domestic Quarrel 33 Other Negligent Wpn Handling D Criminal attempted flight from a crime _ 7 Mercy Killing 35 Other Negligent Killings E Criminal killed in comminsion of a crime _ _ 8 Other Felony F Criminal resisted arrest G Unable to determine _ 10. BIAS MOTIVATION (As applicable) 0Yes0No X0Unknown Section III - Subject la. SUBJECT lb. NAME (Last, First, Middle Nam2.,J9., Sr., Iln„:.. lc. SSN/FNN/ALIEN REG NO: ld. PROTECTED IDENTITY: NO: 1 I_ 64C-S LUG-SSN illMIIIIP .6r/C--1/45-( --$. le. CATEGORY: 1f. DOB (YYYY/MM/DD): 1g. POB: Ci0, State, Country:0, lh. GRADE: 11. HOME PHONE: X A Army WC-S(! 'MM. PVT 1111111111101 - C Coast Guard 1j. WORK PHONE: 1k. NICKNAMES/ALIAS: 11. CITIZENSHIP: F Air Force _ US0 Country (Specify): . H Public Health - Resident Alien: M Marine _ / N Navy lm. COMPONENT ln. DRIVER LICENSE 10. S LICENSE _ 0 NOAA G Nat'l Guard NO: FR Foreign00State (Specify): _ P Family Member X R Regular0V Reserves IT International -Q Civil Service R Civilian 2a. ORGANIZATION, UIC, STREET 2b. INSTALLATION/CITY:0. 2d. Zip/APO: _ S Contractor ADDRESS: FORT DRUM 13602' _ _ T Other Gov. Empl. 2-14 IN C CO, WALVCO 2c. STATE/COUNTRY: 2e. UNIT PHONE: 10110 N RIVA RIDGE U Foreign Nat'l Empl. V Other Foreign Nat'l _ NY US - 3a. RESIDENCE STREET ADDRESS: 3b. INSTALLATION/CITY: 3d. ZIP/APO:LI c_s.-• W Retired Militaryry M. b9-c-s-U7-5 M. ri 4. 5-3c. STATE/COUNTRY: MIND 14.9.0-S' i 6&-t.5-0. 4a. HAIR COLOR 4b. EYE COLOR 4c. COMPLEXION 4d. AGE 5. JUVENILE 7. RACE Brown X Brown Albino X Medium RANGE _ Blond Black Black Medium Brown ( Specify ) -Yes _ A Asian/Pac. Islander _ X Black ____ Gray Dark Ruddy X No B Black _ Gray Blue Dark Brown Yellow I American Indian/ ----4e. HEIGHT 6. SEX _ _ _ Red Green Fair Sallow Alaskan Native - 5 ft. 10 In. 5-C Male -White Hazel -Light -Olive X W White ---Female Other (Specify) Violet Light Brown0 U Unknown 4f . WEIGHT: - Unknown 175 8. ETHNICITY 9. IDENTIFYING MARKS AND LOCATION: 193C-S-( oc,-.5-10. HOW DRESSED AT TIME OF INCIDENT (Clothing, Materials, Colors): X H Hispanic _ N Not of Hispanic Origin 11. OFFENDER'S DISPOSITION: BLACK SHORTS, RED T-SHIRT _ 0U Unknown , WI-1/RED SNEAKERS 12. SECURITY CLEARANCE 13. MARITAL STATUS 14. SUBJECT ARMED WITH ( Check up to 2 and indicate in 2nd box whether X None Annulled F - Fully Automatic, M - Manual, S - Semi-Automatic, U - Unknown ) _ Confidential Divorced X 1 Unarmed 16 Lethal Cutting Instrument _ -Secret _ Divorce Decree, Not Finalized 11 Firearm (Unk Type) 17 Club/Blackjack/Knuckles Top Secret Legally Separated 12 Handgun 15 Other (Specify) Other (Specify) X Married 13 Rifle0 "0" 0 U i 0J) 2 Single 14 Shotgun - Widowed _ DA FORM 3975, JUN 2001 01101-2004-MPC552_DA FORM 3975, MAY 88, IS OBSOLETE_ Page 2 of 6 Pages 15a SUBJECT INVOLVEMENT 15b APPREHENSION TYPE 15c. APPREHENSION DATE 15d. APPREHENDING PMO (UIC/MPC): Accessory Military (YYYY/MM/DD): - Conspiracy Surrender 15e DETENTION TYPE 15f. HOW DRESSED AT TIME OF APPREHENSION: X Civil Authorities -N Non-Uniformed Svc. SEE BLOCK #10 Solicit Other (Specify) -U Uniformed Svc. 15g DISPOSITION OF PERSON UNDER 18 YEARS 15h. FBI FORM 249 SUBMITTED 16a INVOLVEMENT 16b. ALCOHOUDRUG H Handled Internally Yes2X2No Alcohol TEST RESULTS: _ _ R Referred to Other Authorities (Specify) Drug - 15i. FBI FORM R-84 SUBMITTED X None Yes2X2No - 16c. ILLNESS/INJURY: 16d. ALCOHOUDRUG INVOLVEMENT REMARKS: 17a CHEMICAL TEST TYPE 17b DRUG TYPE _ - Blood Test oo A "Crack" Cocaine G Opium M Other Stimulants _ _ _ Breathalyzer B Cocaine -H Other Narcotics N Barbiturates _ - - -Saliva Test C Hashish I LSD 0 Other Depressants _ _Urine Test -D Heroin -J PCP P Other Drugs _ -Other (Specify) E Marijuana K Other Hallucinogens Q Steriods _ - F Morphine -L Amphetamines/Methamphetamines -M Unknown Type Drug _ 17c. DRUG TEST AND MEASUREMENT i.e.: parts per million, cubic centimeters, etc.) 17d. DRUG DETECT ON BY OTHER LAW ENFORCEMENT MEANS2Yes2X_No Section IV Victim - la. VICTIM 1b. NAME (Last, First, Middle Name, JR., Sr., Ill): 1c. SSN/FNN/ALIEN REG NO: 1d. PROTECTED IDENTITY: NO: 1 UNKNOWN ' EPW", SSN 1 e. CATEGORY: 1f. DOB (YYYY/MM/DD): 1g. POB: City, State, Country: 1h. GRADE: 11. HOME PHONE: A Army _ C Coast Guard 1j. WORK PHONE: 1k. NICKNAMES/ALIAS:2-11. CITIZENSHIP: -F Air Force R2 _ • US2 Country (Specify): H Public Health - Resident Alien: M Marine N Navy _ 1m. COMPONENT 1n. DRIVER LICENSE 10. S LICENSE 0 NOAH - -G Nat'l Guard NO: FR Foreign2 , 0State (Specify): P Family Member -R Regular V Reserves IT International -Q Civil Service R Civilian - 2a. ORGANIZATION, UIC, STREET 2b. INSTALLATION/CITY: 2d. Zip/APO: Sontractor C _ ADDRESS: T Other Gov; Empl. _ U Foreign Nat'l Empl. -2c. STATE/COUNTRY: 2e. UNIT PHONE: _ V Other Foreign Nat'l UNKNOWN ADDRESS IZ - W Retired Military 3a. RESIDENCE STREET ADDRESS: 3b. INSTALLATION/CITY: 3d. ZIP/APO: 3c. STATE/COUNTRY: • 4a. TYPE OF VICTIM: 4b. SEX 4c. AGE 4d. RACE 4e. ETHNICITY B Business _ R Religious Male x Under 24 Hours -A Asian/Pac. Islander --H Hispanic F Financial S Society/Public Female 1 -6 Days Old B Black N Not of Hispanic Origin G Government 0 Other _ Unknown 7 - 364 Days Old I American Indian/ U Unknown _ X I Individual U Unknown Years Old Alaskan Native -_ Range (Specify): W White _ U Unknown 5. BIAS MOTIVATION2Yes2X_No ( Check Applicable Bias ) _ - AK Anti-Female Homosexual AU Anti-Protestant _ _ _ AA Anti-Athiest/Agnostic AL Anti-Heterosexual AV Anti-White _ _ _ AB Anti-Alaskan Nativean AM Anti-Hispanic AW Anti-Homosexual Bias span _ _ _ AC Anti-American Indian -AN Anti-Islamic(Moslem) _ AY Anti-Other Religion AD Anti-Arab AO Anti-Jewish AZ Anti-Other Ethnicity _ _ AE Anti-Asian AQ Anti-Male Homosexual BA Anti-Mental Disabili _ 21 _ AG Anti-Bisexual AR Anti-Multi-Racial Group BB Anti-Physical Disab24 4 .-3 a _ _ AH Anti-Black AS Anti-Multi-Religious Group BC Sexual Harassment Al Anti-Catholic AT Anti-Pacific-Islander AX Unknown Bias __ DA FORM 3975, JUN 2001_01101-2004 MPC552 DA FORM 3975, MAY 88, IS OBSOLETE Page 3 of 6 Pages 6. RELATIONSHIP OF VICTIM TO OFFENDER ( For multiple offender relationships, 7. VICTIM — Accessory X Principle enter the subject's number ) INVOLVEMENT — Conspiracy Solicit _ .--- AA Spouse AV Step-Sibling BL Homosexual Relationship 8. INJURY TYPE ( Check up to fve ) _ AB Child AZ Friend —_ BN Extended Family _ B Broken Bones 0 Major njury _ _ AC Sibling BA Neighbor BY Employee _ I Possible Internal T Tooth Loss _ AD Parent BB Corn. Law Spouse BZ Employer L Severe Laceration U Unconsciousness _ — AE Parent-in-Law BC Acquaintance BX Stranger M Minor Injury Z None — _ — AF Step Child BD Baby-Sittee(baby) CA Otherwise Known — — 9 a. DD FORM 2701 PROVIDED VICTIM AG Grandparent BE Boy/Girlfriend 1 CB Relationship Unknown — _ Yes2x.No AH Step-Parent BF Child of Boy/Girlfriend VO Offender _ AK Grandchild BH Former Spouse 9b. IF NOT PROVIDED, WHY NOT?2-Declined2X_Not Required Section V - Persons Related To Report — la. PERSON RELATED TO REPORT NUMBER lb. STATUS — Civil Authorities Complaint2X_Military Police — 1 Sponsor Witness lc. NAME (Last, First, Middle Name, JR., Sr., III): ld. SSN/FNN/Alien Reg No: le. CITIZENSHIP r— US2 Resident Alien I2/04;4 L(0(2-•( 6r9C-(((015 -I Country (Specify): 11. CATEGORY: 1g. DOB (YYYY/MM/DD): lh. POB: City, State, Country: li. GRADE: 1j. HOME PHONE: A Army 1k. WORK PHONE: 11. NICKNAMES/ALIAS: lm. COMPONENT G Nat'I Guard — C Coast Guard R Regular V Reserves — F Air Force _ H Public Health ln. DRIVER LICENSE NO: lo. S LICENSE _ M Marine FR Foreign2State (Specify):2Other (Specify): _ _ . N Navy IT International _ 0 NOAA _ , 2a. ORGANIZATION, UIC, STREET ADDRESS: 2b. NSTALLATION/CITY: ,, 2d. ZIP/APO:P Family Member USACIDC FORT DRUM 13602 — Q Civil Service , MDI — R Civilian 2c. STATE/COUNTRY: 2e. UNIT PHONE: _ S Contractor NY US T Other Gov. Empl. 3a. RESIDENCE STREET ADDRESS: 3b.1,NSTALLATION/CITY: 3d. ZIP/APO: U Foreign Nat'I Empl. — V Other Foreign Nat'l 3c. STATE/COUNTRY: . W Retired Military 4a. DD FORM 2701 PROVIDED VICTIM/WITNESS: 4b. IF NOT PROVIDED WHY NOT? 5. NUMBER OF VICTIMS ( 0 ) AND WITNESSES ( 0 ) Yes2, X2No ElDeclined2X2Not Required NOTIFIED. WITH DD FORM 2701 Section VI - Property la. ITEM NO: lb. CODE: lc. QUANTITY: ld. VALUE: 1 e. DESCRIPTION lf. SERIAL NUMBER: 1 40 1 PHOTOGRAPH 1g. DATE RECOVERED (YYYY/MM/DD): lh. DATE RETURNED (YYYY/MM/DD): li. SECURITY 1j. PROPERTY OWNERSHIP 2004/05/17 _ X S Secured — A Federal E Foreign Govt. lk. PROPERTY LOSS TYPE ( Check all that apply ) — U Unsecured B State X F Private 1 None 5 Recovered — — Z Unknown C City U Unknown 2 Burned X 6 Seized _ _ D County/Borough 3 Counterfeited/Forged 7 Stolen 4 Damaged/DestroyedNandalized PROPERTY DESCRIPTION CODE TABLE 01 Aircraft2 12 Farm Equipment2 23 Office-Type Equipment2 34 Structures-Storage 02 Alcohol2 13 Firearms2 24 Other Motor Vehicles2 35 Structures-Other 03 Automobile2 14 Gambling Equipment225 Purse/Handbag/Wallet2 36 Tools/Hand and Power 04 Bicycle2 15 Heavy Construction Equip.226 Radio/TVNCR2 37 Trucks 05 Buses2 16 Household Goods227 AudioNisual Recording2 38 Vehicle Parts/Accessories 06 Clothing/Furs2 17 Jewelry/Precious Metals228 Recreational Vehicle2,239 Watercraft 07 Computer Hard/Software218 Livestock2 29 Structure-Single Occupancy 240 OTHER (Specify) 08 Consumable Goods219 Merchandise2 30 Structures-Other Dwellings 09 Credit/Debit Cards220 Money2 31 Structures-Commercial/Business 10 Drugs/Narcotics (See below) 221 Negotiable Instruments232 Structures-Industry/Manufacturing 241 Pending In4ripiy ‘..;y ': 4 11 Drugs/Narcotics Equipment222 Non-Negotiable Instruments233 Structures-Public/Community242 Special Category DRUG/NARCOTIC MEASURES GM - Gram2KG - Kilogram2OZ - Ounce LB - Pound2FO - Fluid Ounce2GL - Gallon LT - Liter ML - Milliliter2DU - Dosage Unit2NP,- Number of Plants _ _ DA FORM 3975 , JUN 2001 01101-2004-MPC552 Page 4 of 6 Section VII - Narrative ON 20040417 MILITARY POLICE DESK SGT REPORTED THAT PV111111111111MPOSSESSED PHOTOGRAPH—A S DEPICTING SUSPECTED ABUSE OF A WAR (EPW) WHICH MAY HAVE OCCURRED WHILE DEPLOYED IN IRAQ. WHILE STATE POLICE WERE INVESTIGATING A VERBAL DOMESTIC INCIDENT, IT WAS DISCOVERED THAT PVTIIIIIMIMPOSSESSED A PHOTOGRAPH OF HIMSELF POINTING WHAT APPEARS TO BE A PISTOL AT AN UNIDENTIFIED EPW), WHOSE HANDS WERE TIED AND HIS HEAD COVERED LAYING DOWN. ON 20040418.AS INTERVIEWED AND READ HIS RIGHTS WHICH HE WAIVED RENDERIN A WRITTEN STATEMENT AD ITTING TO BEING PHOTOGRAPHED WHILE POINTIN A BB GUN AT AN (EPW) AND THAT THE INCIDENT OCCURRED WHILE DEPLOYED WITH HIS UNIT. .TATED THAT ELEMENTS OF HIS UNIT WERE SUPPORTING SPECIAL FORCES UNITS IN THE AREA AT THE TIME OF THE INCIDENT..ENIED POINTING AN ACTUAL PISTOL AT THE (EPW), BUT RATHER USING A BB GU idurv -D IN LIEU OF IS AS IGNED WEAPON. _ALSO STATED THAT AS PART OF HIS (EPW) HANDLING PROCEDURES, HE WAS DIRECTED BY THE SPECIAL FORCES SOLDIERS TO MAINTAIN HIS WEAPON POINTED AT THE (EPW). IIIIIIIIMNOSTATED THAT HE WAS UNABLE TO POSITIVELY IDENTIFY THE INDIVIDUAL WHO PHOTOGRAPHED HIM AT THE TIME OF THE INCIDENT. ON 20040518 BASED ON THE EVALUATION AND THE SENSITIVITY OF THE INFORMATION, THE BATTALION OPERATIONS OFFICER DIRECTED THIS INVESTIGATION BE REPORTED UNDER SSI CRITERIA.. , 1. Enclosures: 0 2. Distribution: 0 3. Name: -- DES 4. Grade: GS13 5. Title Of Reporting Official: DIRECTOR, DES 6. Signature: _ DA FORM 3975, JUN 2001 01101-2004-MPC552_ 5_ Page 5 of ,i5 MILITARY POLICE REPORT - ADDITIONAL PERSONS RELATED TO REPORT For use of this form, see AR 190-45; the proponent agency is ODCSOPS This form is a continuation of SECTION V, DA Form 3975. Please attach it to DA Form 3975 when completed. PRIVACY ACT STATEMENT AUTHORITY:_Title 10 United States Code Section 301 Title 5 United States Code Section 2951 Executive Order 9397 dated Nov 22, 1943(SSN) PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified. ROUTINE USES:_Your Social Security Number is used as an additional/alternate means of identification to facilitate filing and retrieval. DISCLOSURE:_Disclosure of your Social Security Number is voluntary. MILITARY POLICE REPORT NUMBER DATE( YYYY/MM/DD) ORI NUMBER USACRC CONTROL NUMBER 01101-2004-MPC552 2004/05/18 NY02200DM THRU: TO: COMMANDER FROM:_. 10110 N RIVA RIDGE ATTN: DIRECTORATE OF EMERGENCY FORT DRUM,NY US 13602 SERVICES P10715 MT BELVEDERE BLVD SECTION V - PERSONS RELATED TO REPORT — la. PERSON RELATED TO REPORT NUMBER lb. STATUS — Civil Authorities Complaint0X_Military Police 2 Sponsor Witness lc. NAME (Last, First, Middle Name, JR., Sr., Ill): ld. SSN/FNN/Alien Reg No: le. CITIZENSHIP —' US0 Resident Alien illiIIIIIIIIIIIIIIIPb0-0-' 1 t 6(0 MIND 6q.C.-1 ( 96— / Country (Specify): lf. CATEGORY: 1g. DOB (YYYY/MM/DD): 1h. POB: City, State, Country: 1i. GRADE: 1j. HOME PHONE: A Army — 1k. WORK PHONE: 11. NICKNAMES/ALIAS: 1m. COMPONENT G Nat'l Guard C Coast Guard R Regular V Reserves — F Air Force _ H Public Health ln. DRIVER LICENSE NO: lo. S LICENSE M Marine FR Foreign0State (Specify):0Other (Specify): _ N Navy IT international — 0 NOAA — 2a. ORGANIZATION, UIC, And STREET ADDRESS: 2b. NSTALLATION/CITY: 2d. ZIP/APO:. P Family Member USACIDC FORT DRUM 13602 Q Civil Service — MD1 R Civilian 2c. STATE/COUNTRY:0,, 2e. UNIT PHONE: _ S Contractor NY US T Other Gov. Empl. _ 3a. RESIDENCE STREET ADDRESS: 3b. INSTALLATION/CITY: 3d. ZIP/APO:U Foreign Nat'l Empi. — V Other Foreign Nat'l — 3c. STATE/COUNTRY: W Retired Military 4a. DD FORM 2701 PROVIDED VICTIM/WITNESS: 4b. IF NOT PROVIDED, WHY NOT? 5. NUMBER OF VICTIMS ( 0 ) AND WITNESSES ( 0 ) Yes0 X_No Declined0X0Not Required NOTIFIED WITH DD FORM 2701 Cu ia ,„' 4: ':' 6 _ _ DA FORM 3975-4, JUN 2001 01101-2004-MPC552 Page 6 of 6