— FBI Seattle, Spokane RA Indian Country Case Intake Form

Requestor Name

Requestor Email

Date of Incident

Name of Subject(s) Subject Name 1 (DOB) Subject Name 2 (DOB) Subject Name 3 (DOB)

Subject an enrolled tribal member?

Yes
No

If yes, provide Tribal Enrollment Number (TEN)

Which Tribe?

If other, please specify

Does the subject have a TRIBAL criminal record?

Yes
No

Name of Victim(s) Victim Name 1 (DOB) Victim Name 2 (DOB) Victim Name 3 (DOB)

Victim enrolled tribal member?

Yes
No

If yes, provide Tribal Enrollment Number (TEN)

Which Tribe?

Did the incident occur within the confines of reservation or tribal trust land?

Yes
No

Brief summary of incident

characters remaining

For physical abuse or sexual assault cases please answer the following questions

For physical abuse, provide date of medical examination.

For sexual assault, provde date of SANE exam

Privacy Act Statement

Privacy Act Statement: The FBI is authorized to collect the information on this form by one or more of the following statutes: Title 28, United States Code (U.S.C.) Sections (§§) 533 and 534; 28 U.S.C. § 0.85; 18 U.S.C. §§ 1152 and 1153. Submitted information will enable the FB to provide investigative assistance related to Indian Country matters. You do not have to provide the requested information, but failure to do so may delay a response to your request. The information collected on this form will be maintained in the FBI Central Records System, Justice/FBI-002, notice of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998). The information provided may be disclosed in accordance with the routine uses contained in this notice or as otherwise permitted by law.

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FBI Seattle, Spokane RA Indian Country Case Intake Form

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