SOCIAL SECURITY ADMINISTRATION
Facsimile Transmittal Sheet
TO:
Central Records
|
FROM:
|
COMPANY:
CT Department of Corrections
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DATE:
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FAX NUMBER:
(860) 292-3453
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TOTAL NO. OF PAGES INCLUDING COVER:
COVER ONLY
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PHONE NUMBER:
(860) 292-3486
RE:
Prisoner Information
NOTES/COMMENTS:
Please send information regarding all confinements and convictions from ______________
to the present for:
Name:___________________________________________________________________
Date of Birth:_____________________________________________________________
Social Security Number:____________________________________________________
Inmate Number:__________________________________________________________
INFORMATION NEEDED:
Dates of Confinement:
Dates of Conviction:
(or official date of parole revocation)
Types of Offense(s) (Felony or Misdemeanor):
(for convictions prior to 04/01/00)
Length of Sentence:
Date of Release, if any:
Type of Release (Parole, Adult Probation, Community Release, etc.):