EFTA01651488.pdf

U.S. Department of Justice Office of the Deputy Attorney General Briefing RSVP November 12, 2020 - Miami, FL PLEASE USE THIS FORM ONLY TO ANSWER THE QUESTIONS ASKED. PLEASE DO NOT USE THIS FORM TO SUBMIT SUBSTANTIVE COMMENTS ABOUT ANY PRIOR OR ONGOING CRIMINAL CASE, OR TO REPORT ANY DETAILS OF ABUSE OR OTHER CRIMINAL CONDUCT. Please fill out the following form and return to the email box by November 2, 2020. Full Name: name as it appears on government ID Email Address: Email Address Phone Number: Phone Number Social Security Number: ',ocial Security Number Address 1: Address 1 Address 2: Apr. / Ste./ Floor City: State: ..ite Zip: Zip code Date of Birth: Iv, /DO irlY Citizenship: Citizenship Country of Birth: Country of Birtr. Will you attend? Yes, I will attend ❑ No, I will not attend Do you need travel arrangements? Yes, I need travel arrangements ^ No, I do not need travel arrangements If yes, which mode of transportation do you prefer? Air C Rail Bus C Mileage reimbursement (if you are utilizing your own vehicle) Only economy, roundtrip fares and one checked luggage bag per person will be authorized. You will be responsible for any incidental charges incurred such as in-flight snacks, Pay-Per-View, Wi-Fi, etc. Airport / station of origin: -orne Airoo•t or Station Preferred date and time of departure from origin: Home Airport or Station Preferred date and time of departure from Miami: Home Airport or Station Do you need lodging? Only two nights of lodging will be authorized and only hotel room cost and tax will be authorized. You will be required to provide a credit card for incidental charges upon check in. You will be responsible for any incidental charges incurred such as snacks, mini bar, Pay-Per-View, phone charges, etc. Yes, I need lodging C No, I do not need lodging EFTA01651488 Do you need ground transportation? Dal will reimburse the costs of parking, ground transportation from home to airport/station, from airport/station to hotel and/or to FBI Building but not for any other local travel. Please keep all receipts. Yes, I need reimbursement for ground transportation No, I do not need reimbursement for ground transportation Will your attorney participate in the meeting? Please note that DOJ will not be able to support any costs related to your attorney's participation. 2 Yes, my attorney will participate in the meeting No, my attorney will not participate in the meeting If yes, what is the name of your legal representative: Click or tap here to enter text. Will you be traveling with a support person? You are authorized to bring one support person for your travel, although that person will most likely not be able to enter the FBI building due to COVID-19 protocols. Yes, I will bring one support person C No, I will not bring a support person Information on support person traveling with you (if any) Support Person's Name: Support person's name as it appears on their government ID Relationship: Relationship Email Address: Email Address Phone Number: Phone Number Social Security Number (if any)*: If applicable. Address 1: Address 1 Address 2: A:2(2r ,rss 2 City: City State: State Zip: Lip Co;.;: Citizenship: Citizenship Date of Birth: fv1M/DD/YVY Country of Birth: Country of Birth *This information is needed in order to enter the FBI Building. Will your support person need travel arrangements? Yes, my support person will need travel arrangements C No, my support person will not need travel arrangements If yes, which mode of transportation do they prefer? Air C Rail Bus C Mileage reimbursement (if they are utilizing their own vehicle) Only economy, roundtrip fares and one checked luggage bag per person will be authorized. You will be responsible for any incidental charges incurred such as in-flight snacks, Pay-Per-View, Wi-Fi, etc. Airport / station of origin: Home airport or station. Preferred date and time of departure from origin: Home airport or station. Preferred date and time of departure from Miami: Home airport or station. 2 EFTA01651489 If bringing a support person, will your support person need separate lodging? Only two nights of lodging will be authorized and only hotel room cost and tax will be authorized. You will be required to provide a credit card for incidental charges upon check in. You will be responsible for any incidental charges incurred such as snacks, mini bar, Pay-Per-View, phone charges, etc. Yes, my support person will need separate lodging No, my support person will not need separate lodging If bringing a support person, will your support person need ground transportation? Dal will reimburse the costs of parking, ground transportation from home to airport/station, from airport/station to hotel and/or to FBI Building but not for any other local travel. Please keep all receipts. Yes, my support person will need reimbursement for ground transportation No, my support person will not need reimbursement for ground transportation Acknowledgement and Signature (Block 1) By checking and signing below, I acknowledge I have read and understand that only lodging, lodging taxes, mileage, and commercial transportation expenses (airfare, bus, train, and hotel transportation only) will be authorized as outlined above. I understand that the following will not be included/provided in the authorized expenses: meals, rental vehicle, entertainment, or other incidental charges. Yes, I acknowledge the above statement Signature Click or tap here to enter text. Date: MM/DD/YYYY Acknowledgement and Signature (Block 2) By checking and signing below, I confirm that I will not undertake travel to the meeting if the answer to either of the Covid-19 questions below is "yes" at the time of travel. I further acknowledge that I have read and understand the COVID-19 protocols in place for this meeting, including the Temperature Screening, and confirm that I will abide by the protocols during the meeting and at all times while inside the FBI building. Yes, I acknowledge the above statement Signature Click or tap here to enter text. Date: MM/DD/YYYY COVID-19 QUESTIONS: 1. Do I currently have a fever, cough, shortness of breath or difficulty breathing, repeated shaking from chills, muscle pain, sore throat new loss of taste or smell, or any other flu-like symptoms? 2. In the past 14 days, have I been in close (less than 6 feet) and prolonged (more than 15 minutes) contact with someone with presumptive or confirmed COVID-19 without wearing a face covering or mask? 3 EFTA01651490