Sample ICE Form 73-049.pdf
PDF 627 KB Posted
- Solicitation number
- ICEOCIO-FMO-01062025
- Issued by
-
Immigration and Customs Enforcement
About this file
This is ICE Form 73-049, a Confidential Transaction Receipt form used by U.S. Immigration and Customs Enforcement (ICE) for documenting payments made to confidential informants (CIs) and other recipients in furtherance of ICE investigations. The 4-page form includes sections for payment requests, payment execution via debit card/check/wire transfer, return of unused funds, and receipt confirmation. It requires multiple signatures from requesting agents, approving officials, witnesses, and recipients, with specific routing instructions for different copies (CI File, Mission Support/FLMU, Dallas Finance Center, and CI receipt). The form captures key details including control numbers, CI information, case numbers, payment amounts, moiety status, and contains a declaration that payments are considered taxable income reportable to the IRS.
The form appears in connection with a Request for Information (RFI) from ICE's Office of Acquisition seeking vendors capable of providing Adobe Form Design and Development Services. The sample form demonstrates the type of forms that would need to be designed under the potential contract. ICE notes that responses to the RFI must be submitted via Microsoft Forms and will not be compensated, with all submissions becoming government property.
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| File | Type | Posted |
|---|---|---|
| Sample ICE Form 70-605 5.pdf | ||
| General Statement of Work.docx | DOCX document |
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Text version
PAYMENT REQUEST
PAYMENT BY DEBIT CARD/CHECK
TRANSFER OF FUNDS BY WIRE
RETURN OF UNUSED FUNDS
RECEIPT OF FUNDS
37. Signature
43. Received from U.S. Immigration and Customs Enforcement (ICE) for information provided to ICE in furtherance of an ICE investigation. Funds awarded for information provided to ICE are considered to be taxable income to the recipient and are required to be reported to the Internal Revenue Service.
33. Print Name/Title/Office 34. Signature
36. Print Name/Title/Office
39. Method of Return
35. Date Funds Received
Part 1 – CI File/Field CI File Custodian/HQ CI File Custodian
32. Amount of Funds Received
TITLES AND SIGNATURES
OF AGENTS
RECEIVING FUNDS
(Two Signatures Required)
DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
CONFIDENTIAL TRANSACTION RECEIPT
3. Obligation No.
6. Confidential Informant No. (If Applicable)
9. Type of Transaction 11. If Other, Specify
13. Dollars
10. Funding Source (If other, indicate funding type in box 11)
12. Enter Amount of Funds Requested (Type out)
14. Assumed Name if CI or Real Name if Other
15. Reason for Payment
16. Requesting Agent (Name/Title/Office) 18. Requesting Agent's Signature
1. Control Number 2. ICE Office 5. Date4. CUC Program Code
7. Case Number
19. Final Approving Official (Name/Title/Office)
22. Debit Card Doc Number
25. HQ/Local Approver
23. Check Number
28. Name/Title/Office of Agent Receiving Funds
24. Check Amount
29. Date Funds Received
8. Related FP&F Numbers
17. Date
20. Date
26. Date Approved
31. Date Funds Paid
40. Date of Return
38. Amount of Funds Returned
41. Name/Title/Office of Agent Returning Funds
21. Approving Official's Signature
42. Name/Title/Office of Witnessing Agent
30. Name/Title/Office of Agent Making Payment
ICE Form 73-049 (7/16) Page 1 of 4
44. Amount of Funds Received
45. Moiety Status This payment is in lieu of Moiety This payment is to be deducted from Moiety
Initials of CI's Assumed Name:
48. Signature of Witnessing Agent
50. Print Name/Title/Agency 51. Print Name/Title/Agency
49. Signature of Witnessing Agent
47. Signature of Recipient (Assumed Name if CI or Real Name if Other)
46. Date Funds Received
Signature of Agent Receiving Funds
Signature of Agent Making Payment
Signature of Agent Returning Funds
Signature of Witnessing Agent
Field Confidential Informant Program Administrator's Signature
27. Name/Title/Office of Agent Providing Funds/Check Signature of Agent Providing Funds/Check
Funding String
PAYMENT REQUEST
PAYMENT BY DEBIT CARD/CHECK
TRANSFER OF FUNDS BY WIRE
RETURN OF UNUSED FUNDS
RECEIPT OF FUNDS
37. Signature
43. Received from U.S. Immigration and Customs Enforcement (ICE) for information provided to ICE in furtherance of an ICE investigation. Funds awarded for information provided to ICE are considered to be taxable income to the recipient and are required to be reported to the Internal Revenue Service.
33. Print Name/Title/Office 34. Signature
36. Print Name/Title/Office
39. Method of Return
35. Date Funds Received
Part 2 – Mission Support, Financial and Logistics Management Unit (FLMU) Certified Undercover (CUC) Operation, if CUC operational funds are used. Dallas Finance Center (DFC)
32. Amount of Funds Received
TITLES AND SIGNATURES
OF AGENTS
RECEIVING FUNDS
(Two Signatures Required)
DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
CONFIDENTIAL TRANSACTION RECEIPT
3. Obligation No.
6. Confidential Informant No. (If Applicable)
9. Type of Transaction 11. If Other, Specify
13. Dollars
10. Funding Source (If other, indicate funding type in box 11)
12. Enter Amount of Funds Requested (Type out)
16. Requesting Agent (Name/Title/Office) 18. Requesting Agent's Signature
1. Control Number 2. ICE Office 5. Date4. CUC Program Code
7. Case Number
19. Final Approving Official (Name/Title/Office)
22. Debit Card Doc Number
25. HQ/Local Approver
23. Check Number
28. Name/Title/Office of Agent Receiving Funds
24. Check Amount
29. Date Funds Received
8. Related FP&F Numbers
17. Date
20. Date
26. Date Approved
31. Date Funds Paid
40. Date of Return
38. Amount of Funds Returned (Type out)
41. Name/Title/Office of Agent Returning Funds
21. Approving Official's Signature
42. Name/Title/Office of Witnessing Agent
30. Name/Title/Office of Agent Making Payment
ICE Form 73-049 (7/16) Page 2 of 4
44. Amount of Funds Received
45. Moiety Status This payment is in lieu of Moiety This payment is to be deducted from Moiety
Initials of CI's Assumed Name:
48. Signature of Witnessing Agent
50. Print Name/Title/Agency 51. Print Name/Title/Agency
49. Signature of Witnessing Agent
46. Date Funds Received
Signature of Agent Receiving Funds
Signature of Agent Making Payment
Signature of Agent Returning Funds
Signature of Witnessing Agent
27. Name/Title/Office of Agent Providing Funds/Check Signature of Agent Providing Funds/Check
Funding String
Part 3 – Confidential Informant (CI) ReceiptICE Form 73-049 (7/16) Page 3 of 4
RECEIPT OF FUNDS
43. Received from U.S. Immigration and Customs Enforcement (ICE) for information provided to ICE in furtherance of an ICE investigation. Funds awarded for information provided to ICE are considered to be taxable income to the recipient and are required to be reported to the Internal Revenue Service.
44. Amount of Funds Received
45. Moiety Status This payment is in lieu of Moiety This payment is to be deducted from Moiety
Initials of CI's Assumed Name:
48. Signature of Witnessing Agent
50. Print Name/Title/Agency 51. Print Name/Title/Agency
49. Signature of Witnessing Agent
46. Date Funds Received
ICE Form 73-049 (7/16) Page 4 of 4
INSTRUCTIONSItem No.
Select the option from the drop-down box to indicate the ICE Office
If transaction is part of a Certified Undercover (CUC) operation, then provide the program code for the CUC operation.
Enter the confidential informant (CI) number, if applicable. If the individual receiving funds is not a CI, then make a selection from the drop-down box.
Enter the appropriate FP&F case number(s) associated with the investigating case number in Section 7.
Select the option from the drop-down box to indicate the funding source.
11 Enter other type of funding source not listed in Section 10.
12 Type out the amount of funds requested.
13 Enter the numeric dollar amount.
Select the option from the drop-down box to indicate the type of transaction.
Enter HSI investigating office case number.
Select today's date.
To be provided by HSI Headquarters Mission Support, Financial and Logistics Management Unit (FLMU).
Control number will be current date (entered as YYYYMMDD), military time (hours and minutes), and Confidential Informant (CI) number (do not put SA). If funds will be received by an Undercover Agent (UCA), Source of Information (SOI), or Cooperating Defendant (CD), input these abbreviations followed by the office code in the third section of the control number, e.g., UCAHQ.
14 Provide the assumed name if the recipient is a CI or real name if other.
15 Provide a brief summary explaining the purpose of the transaction.
16 Type name, title, and office of agent requesting payment.
Digital signature of agent identified in Section 16. 18 Select date.
19 Enter name/title of approving official.
21 Digital signature of official identified in Section 19.
22 Debit Card, UC Credit Card or similar Document Number is to be entered by HSI office.
23 Enter check number issued from a CUC.
24 Entered by the CUC operation issuing a check.
25 Enter name of HQ approver or local HSI office approver. A signature is not required for this section.
26 Select date of approval.
27 Enter name, title, and office of agent providing funds or check if issued by a CUC.
28 Enter name, title, and office of agent receiving funds.
29 Select the date funds were received.
30 Enter name, title, and office of agent making payment.
31 Select the date funds were paid.
32-37 To be completed by agents receiving funds via Electronic Funds Transfer.
38-42 To be completed by agents and witnesses returning funds.
44 Write out the amount of funds received and write the numeric dollar amount.
45 Select the option from the check boxes to indicate the Moiety status. A CI must provide the initials of his/her assumed name.
46 Write the date the recipient received the funds.
47 The CI signs his/her assumed name. If not a CI, a signature of the recipient’s true name must be provided.
48-51 Signatures, printed names to include titles and agencies of witnesses to the payment.
WHERE TO SEND COPIES OF THE CONFIDENTIAL TRANSACTION RECEIPT
PART 1 IF PAYMENT IS A POI OR A POE TO A CI, PLACE PART 1 IN THE CI FILE AND SEND A COPY OF PART 1 TO THE HQ CI FILE CUSTODIAN. FOR ALL OTHER PAYMENT TRANSACTIONS DISBURSED TO ANOTHER RECIPIENT, PLACE
PART 1 IN A MASTER FOLDER MAINTAINED BY THE FIELD CI FILE CUSTODIAN.
PART 2 FOR TRANSACTIONS INVOLVING A CI, SEND PART 2 TO FLMU, MISSION SUPPORT, AND THE DALLAS FINANCE CENTER. IF CERTIFIED UNDERCOVER (CUC) OPERATIONAL FUNDS ARE USED, PART 2 WILL ALSO BE
MAINTAINED BY THE CUC CUFFS ADMINISTRATOR.
PART 3 PROVIDE RECEIPT TO CI.
The Field Confidential Informant Program Administrator's Signature is a digital signature. The document is to be reviewed before submitting to the approving official. Signature ensures that the form is completed correctly, the CI file is up to date and complete, and justification documentation has been provided for this payment request.
Top box
Top box Funding String. Enter the funding string provided by HSI Headquarters Mission Support, Financial and Logistics Management Unit (FLMU)
PAYMENT REQUEST
PAYMENT BY DEBIT CARD/CHECK
TRANSFER OF FUNDS BY WIRE
RETURN OF UNUSED FUNDS
RECEIPT OF FUNDS
37. Signature
43. Received from U.S. Immigration and Customs Enforcement (ICE) for information provided to ICE in furtherance of an ICE investigation. Funds awarded for information provided to ICE are considered to be taxable income to the recipient and are required to be reported to the Internal Revenue Service.
33. Print Name/Title/Office
34. Signature
36. Print Name/Title/Office
39. Method of Return
35. Date Funds Received Part 1 – CI File/Field CI File Custodian/HQ CI File Custodian
32. Amount of Funds Received
TITLES AND SIGNATURES
OF AGENTS
RECEIVING FUNDS
(Two Signatures Required)
DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
CONFIDENTIAL TRANSACTION RECEIPT
3. Obligation No.
6. Confidential Informant No. (If Applicable)
9. Type of Transaction
11. If Other, Specify
13. Dollars
10. Funding Source (If other, indicate funding type in box 11)
12. Enter Amount of Funds Requested (Type out)
14. Assumed Name if CI or Real Name if Other
15. Reason for Payment
16. Requesting Agent (Name/Title/Office)
18. Requesting Agent's Signature
1. Control Number
2. ICE Office
5. Date
4. CUC Program Code
7. Case Number
19. Final Approving Official (Name/Title/Office)
22. Debit Card Doc Number
25. HQ/Local Approver
23. Check Number
28. Name/Title/Office of Agent Receiving Funds
24. Check Amount
29. Date Funds Received
8. Related FP&F Numbers
17. Date
20. Date
26. Date Approved
31. Date Funds Paid
40. Date of Return
38. Amount of Funds Returned
41. Name/Title/Office of Agent Returning Funds
21. Approving Official's Signature
42. Name/Title/Office of Witnessing Agent
30. Name/Title/Office of Agent Making Payment ICE Form 73-049 (7/16)
44. Amount of Funds Received
45. Moiety Status This payment is in lieu of Moiety This payment is to be deducted from Moiety Initials of CI's Assumed Name:
48. Signature of Witnessing Agent
50. Print Name/Title/Agency
51. Print Name/Title/Agency
49. Signature of Witnessing Agent
47. Signature of Recipient (Assumed Name if CI or Real Name if Other)
46. Date Funds Received Signature of Agent Receiving Funds Signature of Agent Making Payment Signature of Agent Returning Funds Signature of Witnessing Agent Field Confidential Informant Program Administrator's Signature Field Confidential Informant Program Administrator's Signature. Digital Signature.
27. Name/Title/Office of Agent Providing Funds/Check Signature of Agent Providing Funds/Check Funding String
PAYMENT REQUEST
PAYMENT BY DEBIT CARD/CHECK
TRANSFER OF FUNDS BY WIRE
RETURN OF UNUSED FUNDS
RECEIPT OF FUNDS
37. Signature
43. Received from U.S. Immigration and Customs Enforcement (ICE) for information provided to ICE in furtherance of an ICE investigation. Funds awarded for information provided to ICE are considered to be taxable income to the recipient and are required to be reported to the Internal Revenue Service.
33. Print Name/Title/Office
34. Signature
36. Print Name/Title/Office
39. Method of Return
35. Date Funds Received Part 2 – Mission Support, Financial and Logistics Management Unit (FLMU) Certified Undercover (CUC) Operation, if CUC operational funds are used. Dallas Finance Center (DFC)
32. Amount of Funds Received
TITLES AND SIGNATURES
OF AGENTS
RECEIVING FUNDS
(Two Signatures Required)
DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement
CONFIDENTIAL TRANSACTION RECEIPT
3. Obligation No.
6. Confidential Informant No. (If Applicable)
9. Type of Transaction
11. If Other, Specify
13. Dollars
10. Funding Source (If other, indicate funding type in box 11)
12. Enter Amount of Funds Requested (Type out)
16. Requesting Agent (Name/Title/Office)
18. Requesting Agent's Signature
1. Control Number
2. ICE Office
5. Date
4. CUC Program Code
7. Case Number
19. Final Approving Official (Name/Title/Office)
22. Debit Card Doc Number
25. HQ/Local Approver
23. Check Number
28. Name/Title/Office of Agent Receiving Funds
24. Check Amount
29. Date Funds Received
8. Related FP&F Numbers
17. Date
20. Date
26. Date Approved
31. Date Funds Paid
40. Date of Return
38. Amount of Funds Returned (Type out)
41. Name/Title/Office of Agent Returning Funds
21. Approving Official's Signature
42. Name/Title/Office of Witnessing Agent
30. Name/Title/Office of Agent Making Payment ICE Form 73-049 (7/16)
44. Amount of Funds Received
45. Moiety Status This payment is in lieu of Moiety This payment is to be deducted from Moiety Initials of CI's Assumed Name:
48. Signature of Witnessing Agent
50. Print Name/Title/Agency
51. Print Name/Title/Agency
49. Signature of Witnessing Agent
46. Date Funds Received Signature of Agent Receiving Funds Signature of Agent Making Payment Signature of Agent Returning Funds Signature of Witnessing Agent
27. Name/Title/Office of Agent Providing Funds/Check Signature of Agent Providing Funds/Check Funding String Part 3 – Confidential Informant (CI) Receipt ICE Form 73-049 (7/16)
RECEIPT OF FUNDS
43. Received from U.S. Immigration and Customs Enforcement (ICE) for information provided to ICE in furtherance of an ICE investigation. Funds awarded for information provided to ICE are considered to be taxable income to the recipient and are required to be reported to the Internal Revenue Service.
44. Amount of Funds Received
45. Moiety Status This payment is in lieu of Moiety This payment is to be deducted from Moiety Initials of CI's Assumed Name:
48. Signature of Witnessing Agent
50. Print Name/Title/Agency
51. Print Name/Title/Agency
49. Signature of Witnessing Agent
46. Date Funds Received ICE Form 73-049 (7/16)
INSTRUCTIONS
Item No.
Select the option from the drop-down box to indicate the ICE Office If transaction is part of a Certified Undercover (CUC) operation, then provide the program code for the CUC operation.
Enter the confidential informant (CI) number, if applicable. If the individual receiving funds is not a CI, then make a selection from the drop-down box.
Enter the appropriate FP&F case number(s) associated with the investigating case number in Section 7.
Select the option from the drop-down box to indicate the funding source.
Enter other type of funding source not listed in Section 10.
Type out the amount of funds requested.
Enter the numeric dollar amount.
Select the option from the drop-down box to indicate the type of transaction.
Enter HSI investigating office case number.
Select today's date.
To be provided by HSI Headquarters Mission Support, Financial and Logistics Management Unit (FLMU).
Control number will be current date (entered as YYYYMMDD), military time (hours and minutes), and Confidential Informant (CI) number (do not put SA). If funds will be received by an Undercover Agent (UCA), Source of Information (SOI), or Cooperating Defendant (CD), input these abbreviations followed by the office code in the third section of the control number, e.g., UCAHQ.
Provide the assumed name if the recipient is a CI or real name if other.
Provide a brief summary explaining the purpose of the transaction.
Type name, title, and office of agent requesting payment.
Digital signature of agent identified in Section 16.
Select date.
Enter name/title of approving official.
Digital signature of official identified in Section 19.
Debit Card, UC Credit Card or similar Document Number is to be entered by HSI office.
Enter check number issued from a CUC.
Entered by the CUC operation issuing a check.
Enter name of HQ approver or local HSI office approver. A signature is not required for this section.
Select date of approval.
Enter name, title, and office of agent providing funds or check if issued by a CUC.
Enter name, title, and office of agent receiving funds.
Select the date funds were received.
Enter name, title, and office of agent making payment.
Select the date funds were paid.
32-37 To be completed by agents receiving funds via Electronic Funds Transfer.
38-42 To be completed by agents and witnesses returning funds.
Write out the amount of funds received and write the numeric dollar amount.
Select the option from the check boxes to indicate the Moiety status. A CI must provide the initials of his/her assumed name.
Write the date the recipient received the funds.
The CI signs his/her assumed name. If not a CI, a signature of the recipient’s true name must be provided.
48-51 Signatures, printed names to include titles and agencies of witnesses to the payment.
WHERE TO SEND COPIES OF THE CONFIDENTIAL TRANSACTION RECEIPT
PART 1
IF PAYMENT IS A POI OR A POE TO A CI, PLACE PART 1 IN THE CI FILE AND SEND A COPY OF PART 1 TO THE HQ CI FILE CUSTODIAN. FOR ALL OTHER PAYMENT TRANSACTIONS DISBURSED TO ANOTHER RECIPIENT, PLACE PART 1 IN A MASTER FOLDER MAINTAINED BY THE FIELD CI FILE CUSTODIAN.
PART 2
FOR TRANSACTIONS INVOLVING A CI, SEND PART 2 TO FLMU, MISSION SUPPORT, AND THE DALLAS FINANCE CENTER. IF CERTIFIED UNDERCOVER (CUC) OPERATIONAL FUNDS ARE USED, PART 2 WILL ALSO BE MAINTAINED BY THE CUC CUFFS ADMINISTRATOR.
PART 3
PROVIDE RECEIPT TO CI.
The Field Confidential Informant Program Administrator's Signature is a digital signature. The document is to be reviewed before submitting to the approving official. Signature ensures that the form is completed correctly, the CI file is up to date and complete, and justification documentation has been provided for this payment request.
Top box Top box Funding String. Enter the funding string provided by HSI Headquarters Mission Support, Financial and Logistics Management Unit (FLMU) 8.2.1.4029.1.523496.503679 Confidential Transaction Receipt ICE Form 73-049
| 1. Control Number. Date. Enter 4 digit year, 2 digit month, and 2 digit day (YYYYMMDD). This is a required field.: |
| 1. Enter military time, hours and minutes.: |
| 1. Enter confidential informant (C I) number without S A., e.g., 1943 H Q. If payment is being made to an Undercover Agent (U C A.), Source of Information (S O I), or Cooperating Defendant (C D), enter the code for the specific individual followed by the office code, e.g., U C A. H Q.: |
| 49. Signature of Witnessing Agent. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| 34. Signature of First Officer Receiving Funds. This is a protected field.: |
| 37. Signature of Second Officer Receiving Funds. This is a protected field.: |
| 47. Signature of Recipient (Assumed Name if C I or Real Name if Other). This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| 50. Print Name/Title/Agency.: |
| 51. Print Name/Title/Agency.: |
| 48. Signature of Witnessing Agent. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| 35. Date Funds Received. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 46. Date Funds Received. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 33. Print Name/Title/Office of First Agent Receiving Funds.: |
| 36. Print Name/Title/Office of Second Agent Receiving Funds.: |
| 39. Method of Return (E F T, Check, Other).: |
| 2. ICE Office.: |
| 3. Obligation Number.: |
| 4. C U C Program Code.: |
| 5. Date. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 6. Confidential Informant Number (If Applicable). If the individual receiving funds is not a C I, then make a selection from the drop-down box.: |
| 6. Enter S A.: |
| 6. Enter the numerical number.: |
| 6. Enter your office code.: |
| 7. Case Number.: |
| 8. Related F P and F Numbers. Number for one of the two most significant seizures. 1 of 2.: |
| 8. Number for one of the two most significant seizures. 2 of 2.: |
| 9. Type of Transaction.: |
| 10. Funding Source (If other, indicate funding type in box 11).: |
| 11. If Other, Specify.: |
| 12. Enter Amount of Funds Requested (Type out). : |
| 13. Dollar Amount.: |
| 14. Assumed Name if C I or Real Name if Other.: |
| 15. Reason for Payment.: |
| 16. Requesting Agent (Name/Title/Office).: |
| 17. Date of Requesting Agent's Signature. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 19. Final Approving Official (Name/Title/Office).: |
| 21. Approving Official's Signature. Digital Signature.: |
| 20. Date of Approving Official's Signature. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 22. Debit Card Document Number.: |
| 25. HQ/Local Approver.: |
| 28. Name/Title/Office of Agent Receiving Funds.: |
| 23. Check Number.: |
| 26. Date Approved. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 29. Date Funds Received. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 31. Date Funds Paid. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 40. Date of Return. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 24. Check Amount.: |
| 32. Amount of Funds Received.: |
| 38. Amount of Funds Returned. Dollar Amount.: |
| 28. Signature of Agent Receiving Funds. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| 41. Name, Title, and Office of Agent Returning Funds.: |
| 41. Signature of Agent Returning Funds. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| 42. Name, Title, and Office of Witnessing Agent.: |
| 42. Signature of Witnessing Agent. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| 30. Name/Title/Office of Agent Making Payment.: |
| 30. Signature of Agent Making Payment. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| 38. Amount of Funds Returned (Type out).: |
| 44. Amount of Funds Received. Dollar Amount.: |
| 43. Received from U.S. Immigration and Customs Enforcement (ICE) for information provided to ICE in furtherance of an ICE investigation. Funds awarded for information provided to ICE are considered to be taxable income to the recipient and are required to be reported to the Internal Revenue Service. 44. Amount of Funds Received. Typed Out.: |
| 45. This payment is to be deducted from Moiety.: 0 |
| 45. Moiety Status. This payment is in lieu of Moiety.: 0 |
| Field Confidential Informant Program Administrator's Signature. Digital Signature. To be reviewed before submitting to the approving official. Signature ensures that the form is completed correctly, the C I file is up to date and complete, and a justification memorandum is provided for this payment request.: |
| 18. Requesting Agent's Signature. Digital Signature.: |
| 27. Name/Title/Office of Agent Providing Funds/Check.: |
| 27. Signature of Agent Providing Funds/Check. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Please print and sign in ink.: |
| Initials of C I's Assumed Name.: |
| Funding String: |
File details come from the government source that posted it. Updated .