REQUEST FOR ADMINISTRATIVE REMEDY

U.S. DEPARTMENT OF JUSTICE
Federal Bureau of Prisons

Type or use

ball~poin{ pen.

If attachment,)' are needed, submit four copies. Additional instructions on reverse.

From:

_
LAST NAME,

I~IRST,

MIDDLE INITIAL

INSTITUTION

REG. NO.

Part A- INMATE REQUEST

SIGNATURE OF REQUESTER

DATE

Part B- RESPONSE

DATE

WARDEN OR REGIONAL DIRECTOR

If dissatisfied with this response, you may appeal to the Regional Director. Your appeal must be received in the Regional Office within 20 calendar days aithe date of this response.

ORIGINAL: RETURN TO INMATE

CASE NUMBER:

_

CASE NUMBER:

_

Part C- RECEIPT
Return to:
LAST NAME, FIRST. MIDDLE INITIAL

REG. NO.

UNIT

SUBJECT:

INSTITUTION
_

DATE

RECIPIENT'S SIGNATURE (STAFF MEMBER)