FUGITIVE FELON EXCLUSION FAX REQUEST
SSA 2795-FAX
FORM)
Revision Date: 09/1/2011
CheckOne
|
PC #
|
PC NAME
|
PC FAX NUMBER
|
|
Check One
|
PC #
|
PC NAME
|
PC FAX NUMBER
|
|
1
|
NEPSC
|
(718) 557-3570
|
|
|
5
|
WNPSC
|
(510) 970-1771
|
|
2
|
MATPSC
|
(215) 597-0371
|
|
|
6
|
MAMPSC
|
(816) 936-5970
|
|
3
|
SEPSC
|
(205) 801-2262
|
|
|
7
|
ODO
|
(877) 385-0643
|
|
4
|
GLPSC
|
(312) 575-6931
|
|
|
8
|
OIO
|
(877) 385-0645
|
CAN: _______________________________________ BIC: ________
BOAN: ______________________________________
NAME: ________________________________________________
SUSPENSION DATA
DATE OF: WARRANT _________________ SUSPENSION _________________
ARREST/CONFINEMENT _________ RELEASE _____________________
DUE PROCESS
-
•
DUE PROCESS NOTICE DATE: _________________
-
•
DUE PROCESS PERIOD: ___10-DAY ___30-DAY
-
•
NOTICE NOT REQUIRED ___ (first-party, non-pay status, or closed period)
EXCLUSION CATEGORY
_____T2R Exclusion ____MBR Processing Exclusions ____OTHER (Explain in Remarks)
REMARKS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
PREPARED BY ______________________________________________ DATE _________________
FO CODE ________TELEPHONE
(____)__________________EXT
(_______________)