New York State Intelligence Center

Latham, New York 12110

New York State

NYSIC

Intelligence Center

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# REQUEST FOR INFORMATION FORM

DATE & TIME OF REQUEST

MEMBER/ANALYST ASSIGNED

RICS Control #:

Rank:

Received/Entered By:

Last Name:

Date: Time:

Tax / SS#:

## REQUESTOR'S INFORMATION

Agency Name and ORI: NY03030C9
Command/Unit: Child Exploit T/F
Investigation Type: Child Exploitation
Workplace (Full Address): 26 Federal Plaza, New York, NY 10278
Last Name: <empty>
First Name: <empty>
Rank/Title: Detective
Tax # NYPD Only: <empty>
SSN: <empty>
Date of Appointment: 08/30/1993
Office #: <empty>
Fax #: <empty>
Pager/Cell#: <empty>
Pin: <empty>
TZS/Pct. Of Occ.: <empty>
Compl#: <empty>
Case#: 2017-212
Conferred w/ Requestor Date: <empty>
Time: <empty>
Supervisor's Rank/Full Name: LT <empty>
Phone Number: <empty>

SUBJECT INFORMATION

Last Name: Borgerson First Name: Scott Middle: G

Aliases:

DOB:

Age: 44

Sex:

M

Race: W POB:

Gang Name:

Bldg#

Street:

Apt:

City:

State:

ZIP Code:

Tel#

SSN#

Driver License#:

State/Country: MA

Arrest:

FBI#:

NYSID#: Other State SID#:

# REQUEST FOR INFORMATION FORM (cont.)

## BUSINESS LOCATION & FINANCIAL INFORMATION

Business

Name:

Bldg:

Street:

City

State:

Zip Code

Tel#:

Last Name:

First Name:

(Circle One) Owner/Mgr/Employee

Tax ID#:

Financial Institution:

Account Type:

VEHICLE INFORMATION

Plate #:

State/Country:

Year:

Make:

Model:

No. Doors/Body Style:

Color:

Gray

VIN#:

REMARKS

What have you (Requestor) done?

What needs to be done by NYSIC personnel?

I am requesting a CIAS search of the above named male for the past one year.

EMAIL Request to NYSIC: ciu@nysic.ny.gov OR FAX Request to NYSIC: (You MUST call to verify that your FAX was received!)

EFTA00039516