FUGITIVE FELON EXCLUSION FAX REQUEST
               (SSA 2795-FAX
               FORM)
               Revision Date: 01/03/2025
         
            
               
                  
                  
                  
                  
                  
                  
                  
                  
                  
               
               
                  
                  
                     
                     | CheckOne | PC # | PC NAME | PC FAX NUMBER |  | Check One | PC # | PC NAME | PC FAX NUMBER   | 
               
               
                  
                  
                     
                     |  | 1 | NEPSC | (833) 960-2334 |  |  | 5 | WNPSC | (833) 983-0160 | 
                  
                     
                     |  | 2 | MATPSC | (833) 914-1757 or (215) 597-0371 |  |  | 6 | MAMPSC | (833) 960-2329 | 
                  
                     
                     |  | 3 | SEPSC | (877) 310-6767 |  |  | 7 |  ODO | (877) 385-0643 | 
                  
                     
                     |  | 4 | GLPSC | (833) 914-1646 |  |  | 8 |  OIO | (877) 385-0645 | 
               
            
          
         CAN: _______________________________________ BIC: ________
         
         BOAN: ______________________________________
         
         NAME: ________________________________________________
         
         SUSPENSION DATA
         DATE OF: WARRANT _________________ SUSPENSION _________________
         ARREST/CONFINEMENT _________ RELEASE _____________________
         DUE PROCESS
         
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                  • 
                     DUE PROCESS NOTICE DATE: _________________ 
 
 
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                  • 
                     DUE PROCESS PERIOD: ___10-DAY ___30-DAY
                      
 
 
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                     NOTICE NOT REQUIRED ___ (first-party, non-pay status, or closed period)
                      
 
 
EXCLUSION CATEGORY
         _____T2R Exclusion ____MBR Processing Exclusions ____OTHER (Explain in Remarks)
         
         REMARKS:
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         PREPARED BY ______________________________________________ DATE _________________
         FO CODE ________TELEPHONE
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