RI-004 (09/2014)

MICHIGAN STATE POLICE

Page 1 of 4

MICHIGAN SEX OFFENDER REGISTRATION

AUTHORITY:M.C.L.A. 28.721, et seq. COMPLIANCE:MANDATORY

Agency / Administrator / Phone Number / Date
Your next verification month is:
Registration Tier / Verification Frequency / Registration Status
  1. Offender Information

Full Name / Date of Birth / Race
Sex / Hair / Eye Color / Height / Weight / Last Verification Date
Registration Number / Social Security Number / OPS/PID Number / FBI Number
MI/SID Number / MDOC Number / Immigration Number
Fingerprints On File / Palm Prints On File / DNA On File
Passport On File / Professional License Number / License Type
  1. Residence Information

Address / City / State / ZIP Code / Start Date
  1. Incarceration(s)

(1)Facility Name / Incarceration Start Date / Incarceration End Date / Total Days Incarcerated
Address / City / State / ZIP Code
  1. Contact Information

(1) Telephone Number / Phone Type / (3) Email/Internet / Type / Service Provider
(2) Telephone Number / Phone Type / (4) Email/Internet / Type / Service Provider
  1. Alias(es)

List All Aliases
  1. Scars/Marks/Tattoos (SMT)

(1) SMT Type / SMT Location / SMT Description / (2) SMT Type / SMT Location / SMT Description
(3) SMT Type / SMT Location / SMT Description / (4) SMT Type / SMT Location / SMT Description
  1. Employment Information

Employer Name / Employer Address / County / Volunteer
YES NO / Start Date
  1. Campus/Educational Institution Information

Campus Name / Campus Address / County / Start Date
  1. Vehicle(s)

Make / Model / Style / Color / Year / License / State VIN / Location Kept
Make / Model / Style / Color / Year / License / State VIN / Location Kept
  1. Mobile Home(s)

Make / Model / Style / Color / Year / License / State VIN / Location Kept
Make / Model / Style / Color / Year / License / State VIN / Location Kept
  1. Boat(s)

Make / Model / Style / Color / Year / License / State VIN / Location Kept
Make / Model / Style / Color / Year / License / State VIN / Location Kept
  1. Aircraft(s)

Make / Style / Color / Year / License / Serial Number / Location Kept
  1. Offense Information

Offense Date / Crime Code and Description / Counts / Victim Age / Conv. State / Conv. Date / Case Number
Offense Details
Offense Date / Crime Code and Description / Counts / Victim Age / Conv. State / Conv. Date / Case Number
Offense Details
Offense Date / Crime Code and Description / Counts / Victim Age / Conv. State / Conv. Date / Case Number
Offense Details
Offense Date / Crime Code and Description / Counts / Victim Age / Conv. State / Conv. Date / Case Number
Offense Details
XIV. Registration Fee
Balance Owed / Last Fee Paid / Collecting Agency / Indigent Date / Indigent Agency

Registration Number:

EXPLANATION OF DUTIES TO REGISTER AS A SEX OFFENDER

1. Iamrequiredby lawtoregister as a sexoffender. Failuretoregisterasrequired by lawis afelony andmayresult inprosecution. MCL28.729(1).

a.If IamaTierIoffender, Imust registerfor 15 years.MCL 28.725(10)

b.If IamaTierII offender, I mustregisterfor 25years.MCL28.725(11)

c.If IamaTierIIIoffender, I mustregisterforthe remainder of mylife. MCL 28.725(12)

d.Iunderstandmy registrationperiodexcludesall period(s) of incarceration.MCL 28.725(13)

2. Iamrequired tosigntherequiredregistration form(s). Failuretosigntherequiredregistrationform(s) is amisdemeanor andmay resultincriminal prosecution.

3Iamrequiredby lawtoverifymyaddressby reportingin-personandprovidingproofofresidency atalocallawenforcement agency, sheriff'soffice, or Michigan StatePolice post thathasjurisdictionovermy residence. Failure toverifymy addressasrequiredby lawisamisdemeanor andmayresult in prosecution.

Registration Number:

a.If IamaTierIoffender, I amrequiredby lawtoverifymy address onceevery year duringmymonthof birth. MCL28.725a(3)(a)

b.If IamaTierII offender, Iamrequiredby lawtoverifymy address twiceeachyear accordingtothe followingschedule: MCL28.725a(3)(b)

Birth Month Reporting MonthsBirth MonthReporting Months

January January and JulyJulyJanuary and July

February February and AugustAugustFebruary and August

March March and SeptemberSeptemberMarch and September

AprilApril and OctoberOctoberApril and October

MayMay and NovemberNovemberMay and November

JuneJune and DecemberDecemberJune and December

c.If IamaTierIIIoffender, Iamrequiredby lawtoverifymy address four timeseachyear accordingtothe followingschedule: MCL28.725a(3)(c)

Birth Month Reporting MonthsBirth MonthReporting Months

January January, April, July, and OctoberJulyJanuary, April, July, and October

February February, May, August, and NovemberAugustFebruary, May, August, and November

March March, June, September, and DecemberSeptemberMarch, June, September, and December

AprilJanuary, April, July, and OctoberOctoberJanuary, April, July, and October

MayFebruary, May, August, and NovemberNovemberFebruary, May, August, and November

June March, June, September and, DecemberDecemberMarch, June, September and, December

4. Uponregisteringasasexoffender,I amrequiredby lawtoprovide thefollowinginformation:

a.My legalnameandany aliases, nicknames, tribalnames, ethnic names,andany other nameby whichIhave beenknown.MCL28.727(1)(a)

b.My socialsecurity number andany socialsecurity numbersor allegedsecurity numberthat I havepreviously used.MCL28.727(1)(b)

c.My dateofbirth and any allegeddatesofbirththat Ihave previouslyused.MCL28.727(1)(c)

d.Theaddress whereIresideor will reside. If I donot havearesidentialaddress thenImust provide thelocationthat I useinlieuof aresidence. If I am homeless, thenI mustprovidethenameof thevillage, city,ortownship whereIspendor willspendthemajority ofmytime. MCL28.727(1)(d)

e.Thenameandaddress of any temporary lodgingusedortobeusedwhenIamaway frommy residence formorethansevendays.MCL28.727(1)(e)

f.Thenameandaddress of eachof myemployers.“Employers” includes contractors. Ifmy employment locationis notinafixedlocation, then I must provide the generalareaswhereI workand thenormaltravelroutes that I takewhileworking.MCL28.727(1)(f)

g.Thenameandaddress of any schoolthat I attendorthathasacceptedmeif Iplantoattend.MCL28.727(1)(g)

h. Alltelephonenumbersregisteredtomeorthat I routinely use. MCL28.727(1)(h)

i.Allelectronicmail (e-mail) addressesandinstant messageaddressesassigned tomeorthat I routinelyuse andallloginnamesandotheridentifiers that Iusewhenusinge-mailorinstant messaging. MCL28.727(1)(i)

j.Thelicenseplatenumber,registration number, anddescriptionofanymotor vehicle, aircraft, or vesselthat Iownor regularly operate and thelocation where they areroutinelystored. MCL28.727(1)(j)

k.My passportandallother immigrationdocuments that I mayhave.MCL 28.727(1)(l)

l.Alloccupationalandprofessionallicensinginformationthat Imay have.MCL28.727(1)(m)

5.Duringmy verification periods, I amrequiredby lawtoreviewallofmyregistrationinformation foraccuracy.MCL28.725a(4).

6.Iamrequiredby lawtoreport inpersonwithin threebusiness days toalocallawenforcementagency, sheriff'soffice,or MichiganStatePoliceposthaving jurisdictionovermy residence, allofthefollowing:

a.My newaddressafterchangingorvacatingmyresidence withinthestateofMichigan. If I amhomelessor lackafixedor temporary residence, Iam requiredby lawtoprovide the village,city, or townshipwhereI spend themajority of mytime. MCL28.725(1)(a) andMCL28.727(1)(d)

b.Thenameandaddress ofmy employer uponobtaining, changing, ordiscontinuingemployment,includingvolunteer work.MCL 28.725(1)(b)

c.Thenameandlocationof theschooluponenrollingor discontinuingenrollmentataninstitutionofhigher learning.MCL28.725(1)(c)

d.My newname uponchangingmyname.MCL28.725(1)(d)

e.My temporary addressanddatesoftravelif I intendtotemporarily resideat any place otherthanmyresidenceformore than sevendays. MCL

28.725(1)(e) and MCL28.727(1)(e)

f.Any electronicmail (e-mail)address,instant messagingaddress,orany other designation usedininternetcommunications upon establishingit.MCL 28.725(1)(f)

g.Thelicenseplatenumber or registrationnumber, description,andlocationstoredorkept of any vehiclethat Iownor regularly operate.MCL

28.725(1)(g)

h.My newaddresspriortochangingmyresidence toanotherstate. MCL28.725(6) Failure toreportas required by lawisafelony andmayresult in prosecution.

Registration Number:

7.Iamrequiredby lawtoprovidemynewor temporary addressbyreportinginperson toalocallawenforcement agency, sheriff’soffice, or MichiganState Policeposthavingjurisdiction overmy residence 21dayspriortotraveling toanothercountryformorethan7daysorchangingmyresidence toanother country. Failure toreport this informationis afelony andmay result in criminalprosecution.MCL 28.725(7)

8.TheMichigan DepartmentofCorrections may not releasemeuntilI provide theaddress ofmy proposed placeofresidence. A county jaillocated within Michigan willnotreleasemeuntilI provide the addressof myproposedplaceofresidence.MCL 28.725(3) andMCL 28.725(4)

9.Iamrequiredby lawtomaintaineither a validMichiganoperator’sorchauffeur’s license or Michigan personalidentificationcardwithadigitizedphotograph.This cardmay beusedasproof of residency.Other proofofresidencymay be required, suchasavoterregistrationcard,utility bill,orother bill. Unless otherwise specifiedbylaw, my digitizedphotographwillbeincludedon thepublic sex offender registry website.Failuretomaintain theproper identificationisamisdemeanor andmay result in criminalprosecution.MCL28.725a(7) andMCL28.725a(8)

10. Iamrequiredby lawtopay a$50.00registration feeat thetimeofmy initial registrationandannually following theyear ofinitial registration. Thepayment oftheannualregistrationfeeshallbepaidat thetimeI reportduringthe firstverification reportingmonthforme,unless Ielect toprepay theannual registrationfeefor anyfutureyearfor whichan annualregistration feeis required. Prepayingmy annualregistrationfeedoes not changeor altermy reporting requirements as detailedinsection 3above. Thesumof theamountspaidunder this sectionshallnotexceed$550.00.If Iam determined tobe indigentby thecollectingagency, this feewillbetemporarily waived for 90days. Failure topay theregistration feeis amisdemeanor andmayresult in criminal prosecution. MCL28.725a(6) MCL 28.724a(5),andMCL28.725b(3)

11. Iamrequiredby lawtohavemyfingerprintsandpalmprints takenif they arenotalready onfilewith thedepartment of StatePolice. Thosefingerprints and palmprintswillbeforwarded to theFederalBureauof Investigationifthey arenotalready onfilewiththe FederalBureauof Investigation.Imust be reprinted if myfingerprints or palmprints were expungedand/or returned tome.MCL28.727(1) (q)

12. Unless otherwise specifiedby law, Iamprohibitedby lawfromresidingor workingwithin1,000 feet fromany building, facility, structure,or realproperty owned,leased,or otherwise controlledby apublic, private, denominational,orparochial schoolofferingdevelopmentalkindergarten, kindergarten,or any grade fromonethrough twelve.Residing or workingwithinastudent safety zoneisamisdemeanor andmay result incriminal prosecution.MCL28.735(1), MCL28.734(1) (a)

13. Iamprohibitedbylawfromloiteringwithin1,000feet fromany building,facility, structure,or real property owned,leased,orotherwise controlledby apublic, private,denominational, or parochialschoolofferingdevelopmentalkindergarten,kindergarten, or any grade fromonethroughtwelve.Loiteringinastudent safetyzoneis amisdemeanor andmay result incriminal prosecution.MCL28.734(1) (b)

14. It is afelony toknowingly providefalseormisleading informationconcerningaregistration,notice,orverification, anddoingsomay result inprosecution.MCL28.727(6)

15. Iacknowledge that Ihavereadtheaboverequirements and/or hadthemread tome.

Your next verification month is:

PLEASE READ CAREFULLY BEFORE SIGNING

I have reviewed my registration information and have verified the information is accurate and complete. I understand that failing to comply with the requirements of the Sex Offenders Registration Act is a crime and may result in criminal prosecution.

I acknowledge that I have been provided a written notice explaining my registration duties. I have read the above requirements and/or had them read to me and I understand my registration duties.

SIGNATURES
Signature of Offender / Signature of Notifying Official
Signature of Parent, Legal Guardian, or Power of Attorney, if applicable / Printed Name of Notifying Official
Date / Notifying Agency

SUBMIT COMPLETED FORM VIA MAIL TO:

Michigan State Police

Sex Offender Registry Unit

P.O. Box 30634

Lansing, MI 48909-0634

OR FAX TO: (517) 241-1868