Free Sentencing Memo (Supporting Documents) - District Court of Arizona - Arizona

FORM 13—80A1
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Part AZ (to be completed by inmate/resident)
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inmate/ResidentName: U Q/O
Inmate/Resident Number: [ Q 52 f Date: Jaz O O 6
WorkAssignment;

Work Hours: HousingAssignment:
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Reason for requesting Health ServicesAppointrnent (BE SPECIFIC): & & {2,; Q gg-O xr
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How long have you had this problem? ( [gg Q//Q/U Ui-
Inmate/Resident Signature: gi 2 `
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Print Name; QQ/7§Q&QZ 4¢&(Ag C20 Q3 gmg gggg K
J, DO NOT WRITE BELOW THIS LINE ,;,
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Part B: (to be completed? by Health Services personn;) `
Health Services Reply: 7>_ / _ I
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Health Services ?i ature: I Y 4
Date: I 9
White Copy; To Medical Records Yelloy Cogy; To Inmate During Exam
\ EQ W Property of Corrections Corporation of America
\/ Revised JAN 2005
Case 2:04-cr-01029—I\/IHI\/I Document 69-2 Filed O4/12/2006 Page 1 of 1

Case 2:04-cr-01029-MHM

Document 69-2

Filed 04/12/2006

Page 1 of 1