(08/2008)
Name:
USPO:
Complete this form in full and return to your U.S. Probation Officer within seven days. If you are unsure about
what to report, ask your U.S. Probation Officer. If you need additional space, write on a separate sheet of paper
referencing the item. If an item does not apply mark not applicable or N/A.
Where do you use a computer and/or access the Internet?
9 Home
9 School
9 Work
9 Other (Specify)
Do you use a computer to operate/host a website, electronic bulletin board, list serve, or e-mail service?
9Yes (Explain)
9 No
Do you use a computer to write or publish material for distribution to the public?
9Yes (Explain)
9 No
Do you use a computer to sell merchandise over the Internet?
9Yes (Explain)
9 No
Estimate how often you access your computer.
9 0 to 5 times a week
9 6 to 10 times a week
9 11 to 15 times a week
9 More than 15 times a week
Estimate how many hours a week you are on the Internet?
9 0 to 10 hours a week
9 11 to 15 hours a week
9 16 to 20 hours a week
9 More than 20 hours a week
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NDCA
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Employer Site
Do you have Internet access at work?
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
9 Yes
9 No
School Site
What requires you to have access to the schools computer and/or Internet access?
Name of e-mail account(s) at school.
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NDCA
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RESIDENCE
Internet Service Provider(s) (ISP): If you use more than one ISP, list all and indicate which screen names/e-mail
addresses correspond with the appropriate ISP. If additional space is needed, attach a separate sheet.
ISP
Screen Name
Passwords
Who Has
Access
How Paid?
E-mail Accounts: List any and all e-mail accounts not reflected above. Examples of such accounts are Hotmail and
Yahoo. If additional space is needed, attach a separate sheet.
Provider
Screen Name
Password
Purpose
Screen Name
Password
Purpose
Seller Accounts: List all seller accounts you maintain (eBay, Amazon.com), even if you only use the account to buy
items. If additional space is needed, attach a separate sheet.
Provider
Screen Name
Password
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Purpose
NDCA
(08/2008)
Social Networking Accounts: List all social networking (i.e. My Space) accounts you maintain.
Provider
User Name
Password
Purpose
Websites
List any and all websites and/or locations you have privileges to receive, send, and/or store
information to. If additional space is needed, attach a separate sheet.
Name
Domain Registered to
IP Address
Purpose
Provide complete details regarding any storage locations that are not reflected above.
Remote Storage
Information to include: Location (be specific), how much storage space you have, method for paying for space, purpose
of having this storage space, and password to access location.
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EDUCATION
Provide complete details regarding any certifications you have received (i.e., MCSE).
Certification Title
Date Received
Training Facility
Date Received
Institution
To the best of my knowledge and belief, the information I have provided in this statement is true, correct and complete. I understand
that a false statement on this form may result in a violation of supervision or a separate charge of false statements under 18 U.S.C.
1001 (up to five years imprisonment, a fine of $250,000, or both).
Signature
Date
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NDCA
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Additional Page
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