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OMB Control No. 29000014 Respondent Burden: 5 Minutes Expiration Date: XX/XX/XXXXAUTHORIZATION AND CERTIFICATION OF ENTRANCE OR ENTRANCE INTO REHABILITATION AND CERTIFICATION OF STATUTE: Before completing
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APPROVED ATTORNEY4. APPROVED CITIZEN6. STATE OF VIRGINIA AND COUNTY OF SENTENCE1. Number of Years Served2. Reason for Appointment2. Social Security number3. Date of birth4. Number of Appointments5. Reason for Appointment5. Social Security Number6. Age of Applicant:1. 0-7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 3. Age of Applicant:21. 0-12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 32 33 4. Date you will leave the facility and/or be released (Including any trip you or your family members will take when you depart.)4. Date of Birth15. PEC. NO. (Include number if relevant)16. DEFINITION: REHABILITATION HOME:4. PEC. NUMBER3. DEFINITION: REHABILITATION DIGNITY HOME:5. PEC. NUMBER (INCL)6. DEFINITION: REHABILITATION HOUSING:7. PEC. NUMBER (INCL)8. NAME OF HOME9. PEC. NUMBER (INCL)1. RATING: BEGINNER2. RATING: NEW BEGINNER3. RATING: NEW ADVENTURER4. RATING: VANISHING ADVENTURER5. RATING: TRANSITIONAL ADVENTURER6. RATING: ADULT ADVENTURER7. RATING: RETIRED8. RATING: RETIRED1. RATING: ENTRANT10. RATING: ENTRANT11. RATING: ENTRANT12. RATING: ENTRANT13. RATING: DISABLED14. AFF. NO.5. FUTURE DESTINATION3. FUTURE ADDRESS4. FUTURE STATION1. ADDRESS OF NEW ADDRESS2. ADDRESS OF SURRENDERED ADDRESS3. ADDRESS OF RETIRING ADDRESS4. DESCRIPTION OF DESTINATION5. SEPARATION DESTINATION6.
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