U.S. DEPARTMENT OF JUSTICE

REQUEST FOR ADMINISTRATIVE REMEDY

Federal Bureau of Prisons
Type or use ball�poinr pen. If attachments are needed, submit four copies. Additional instructions on reverse.

LAST NAME, PIRST, MIDDLE INITIAL

REG. NO.

Ui\TT

INSTITUTION

Part A- INMATE REQUEST

DATE

SIGNATURE OF REQUESTER

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 of the date of this response.

ORIGINAL: RETURN TO INMATE
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----·-----------------------------CASE
----NUMBER:
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Part C- RECEIPT
Return to:

LAST NAME, FIRST, MIDDLE INITIAL

REG. NO.

UNIT

INSTITUTION

SUBJECT: ____________________________________________
DATE

RECIPIENT'S SIGN'ATURE (STAFF MEMBER)

Requirement for submission of this request directly to the Regional Director, Bureau of Prisons.
When the inmate helievcs that he may be adversely affected by submission of this request at the institution level hecause of the sensitive nature of the
complaint, he may address his complaint to the Regional Director. He must clearly indicate a valid reason for not initially bringing his complaint to
the attention of the institution staff.
If the inmate does not provide a reason, or if the Regional Director or his clesignee believes that the reason supplied is not adequate, the inmate will
be notified that the complaint has not been accepted. The form sent to the Regional Director will not be returned. However. the inmate may prepare
a new request and submit it at the institution if he wishes.