FALSE STATEMENTS 18 USC 371
Known Detainers/Warrants: N OY - Agency: (Must provide a copy ofsoy detainers)
CAUTIONS AND MEDICAI.
Long Term Medical Conditions (e.g., heart problems, diabetes, asthma. tuberculosis ... Information, or Indictment, if completed ❑ USM-552 (Prisoner Medical Records Release Form)-
O Copy of Detainer(s), if issued completed signed and datedby intake DUSMIDEO
O Copy of Writ