SOP 222.08-att-1: Georgia Sex Offender Registration Notification Form

IIG01-0001
Attachment 1

4/01/2011
# Georgia Sex Offender Registration Notification Form

_*Asterisk denotes required fields (if applicable)_

Offender Information

|* Last Name * First Name * Middle Name|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Probation|Col12|*Fingerprints|Col14|DNA|Col16|*Photograph|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|||||||||||Yes
No|Yes
No|Yes
No|Yes
No|Yes
No|Yes
No|Yes
No|
|*Date of
Birth|Place of
Birth|Place of
Birth|*Age|*Age|*Sex|*Race|*Race|*Height|*Weight|*Weight|*Hair Color|*Hair Color|*Eye Color|*Eye Color|*Social Security Number|*Social Security Number|
||||||||||||||||||
|Driver’s License
Number|Driver’s License
Number|Driver’s
License
State|Driver’s
License
State|*Vehicle Make|*Vehicle Make|*Vehicle Make|*Vehicle Model|*Vehicle Model|*Vehicle Model|*Vehicle Model|*Vehicle Color|*Vehicle Color|*Vehicle
Year|*Vehicle
Year|
*Vehicle Tag Number|
*Vehicle Tag Number|
|
|
||||||||||||||||

Offender’s Additional Information

Name(s)
Scars/ Marks/ Tattoos

Date of Birth (s)

Social Security Number(s)

Vehicle Make
Vehicle Model

Vehicle Color

Vehicle Year
Vehicle Tag Number

Offense Information

*Crime(s)

1

_Revised July 2010_

IIG01-0001
Attachment 1

4/01/2011
# Georgia Sex Offender Registration Notification Form

|Col1|Col2|Col3|Col4|Col5|Col6|Col7|Col8|Col9|Col10|Col11|
|---|---|---|---|---|---|---|---|---|---|---|
|*Date of
Offense|Date of
Arrest|*Prison Release Date|*Prison Release Date|*Probation
Start Date|*Parole Start
Date|*Parole Start
Date|SID Number|SID Number|FBI Number|GDC ID Number|
||||||||||||
|*Date of
Conviction|Court of
Conviction|Court of
Conviction|Case Number|Sex of Victim|Sex of Victim|Age of Victim|Age of Victim|County of Conviction|County of Conviction|*State of
Conviction|
||||||||||||

Place of Employment

|*Name of Employer|*Address|*County|*City|*State|*Zip
Code|*Date of
Employment|
|---|---|---|---|---|---|---|
||||||||

Institute of Higher Learning

|*Name of Institution|*Address|*County|*City|*State|*Zip Code|
|---|---|---|---|---|---|
|||||||

Permanent Place of Residence or Homelessness

|*Complete Street Address or Location Where You Sleep
(if Homeless) or Prison Address Prior to Release|*County|*City|*State|*Zip Code|
|---|---|---|---|---|
||||||
|Complete Mailing Address or P.O. Box|County|City|State|Zip Code|
||||||

Temporary Place of Residence (If applicable)

|Complete Street Address|County|City|State|Zip Code|
|---|---|---|---|---|
||||||
|Complete Mailing Address or P.O. Box|County|City|State|Zip Code|
||||||

Place of Residence (Complete only if no permanent address provided)

| Motor Vehicle or Trailer| Mobile or Manufactured Home| Vessel, Live-Aboard Vessel
or Houseboat|Col4|
|---|---|---|---|
|Vehicle Identification Number|Mobile Home Location Permit Number|Hull Identification|Manufacturer’s Serial|

_Revised July 2010_

2

IIG01-0001
Attachment 1

4/01/2011
# Georgia Sex Offender Registration Notification Form

|Col1|Col2|Number|Number|
|---|---|---|---|
|||||
|License Tag Number|Mobile or Manufactured Home
Owner Name and Address|Name of Vessel or
Houseboat|Registration Number|
||

|||
|Description of Motor Vehicle or Trailer
(Including Make, Model, Color Scheme)|Description of Mobile or Manufactured Home
(Including Make, Model, Color Scheme and Where
Home is Located on Property)|Description of Vessel, Live-Aboard Vessel
or Houseboat
(Including Make, Model, Color Scheme)|Description of Vessel, Live-Aboard Vessel
or Houseboat
(Including Make, Model, Color Scheme)|
|||||

REGISTRATION INFORMATION FOR ALL SEX OFFENDERS

Pursuant to O.C.G.A § 42-1-12(a) (16), “Required registration information” means:

(A) Name; social security number; age; race; sex; date of birth; height; weight; hair color; eye color; fingerprints; and
photograph;
(B) Address within this state or out of state, and, if applicable in addition to the address, a rural route address and a post
office box;
(C) If the place of residence is a motor vehicle or trailer, the vehicle identification number, the license tag number, and a
description, including color scheme, of the motor vehicle or trailer;
(D) If the place of residence is a mobile home, the mobile home location permit number; the name and address of the owner
of the home; a description, including the color scheme of the mobile home; and, if applicable, a description of where the
mobile home is located on the property;
(E) If the place of residence is a manufactured home, the name and address of the owner of the home; a description, including
the color scheme of the manufactured home; and, if applicable, a description of where the manufactured home is located on
the property;
(F) If the place of residence is a vessel, live-aboard vessel, or houseboat, the hull identification number; the manufacturer's
serial number; the name of the vessel, live-aboard vessel, or houseboat; the registration number; and a description, including
color scheme, of the vessel, live-aboard vessel, or houseboat;
(F.1) If the place of residence is the status of homelessness, information as provided under paragraph (2.1) of subsection (f)
of this Code section;
(G) Date of employment, place of any employment, and address of employer;
(H) Place of vocation and address of the place of vocation;
(I) Vehicle make, model, color, and license tag number;
(J) If enrolled, employed, or carrying on a vocation at an institution of higher education in this state, the name, address, and
county of each institution, including each campus attended, and enrollment or employment status; and
(K) The name of the crime or crimes for which the sexual offender is registering and the date released from prison or placed
on probation, parole, or supervised release.

Pursuant to O.C.G.A § 42-1-12(f), Any sexual offender required to register under this Code section shall:

(1) Provide the required registration information to the appropriate official before being released from prison or placed on
parole, supervised release, or probation;
(2) Register in person with the sheriff of the county in which the sexual offender resides within 72 hours after the sexual
offender's release from prison or placement on parole, supervised release, probation, or entry into this state;
(2.1) In the case of a sexual offender whose place of residence is the status of homelessness, in lieu of the requirements of
paragraph (2) of this subsection, register in person with the sheriff of the county in which the sexual offender sleeps within 72
hours after the sexual offender's release from prison or placement on parole, supervised release, probation, or entry into this
state and provide the location where he or she sleeps;
(3) Maintain the required registration information with the sheriff of each county in which the sexual offender resides or
sleeps;

_Revised July 2010_

3

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4/01/2011
# Georgia Sex Offender Registration Notification Form

(4) Renew the required registration information with the sheriff of the county in which the sexual offender resides or sleeps
by reporting in person to the sheriff within 72 hours prior to such offender's birthday each year to be photographed and
fingerprinted;
(5) Update the required registration information with the sheriff of the county in which the sexual offender resides within 72
hours of any change to the required registration information, other than where he or she resides or sleeps if such person is
homeless. If the information is the sexual offender's new address, the sexual offender shall give the information regarding the
sexual offender's new address to the sheriff of the county in which the sexual offender last registered within 72 hours prior to
any change of address and to the sheriff of the county to which the sexual offender is moving within 72 hours prior to
establishing such new address. If the sexual offender is homeless and the information is the sexual offender's new sleeping
location, within 72 hours of changing sleeping locations, the sexual offender shall give the information regarding the sexual
offender's new sleeping location to the sheriff of the county in which the sexual offender last registered, and if the county has
changed, to the sheriff of the county to which the sexual offender has moved; and
(6) Continue to comply with the registration requirements of this Code section for the entire life of the sexual offender,
excluding ensuing periods of incarceration.

_Revised July 2010_

4

IIG01-0001
Attachment 1

4/01/2011

|Initial|Provision|Col3|
|---|---|---|
||A.|According to the provisions of O.C.G.A § 42-1-12, you are hereby notified that you must register in person
as a sex offender in the State of Georgia for life unless relieved of that requirement by a court of competent
jurisdiction.
|
||B.|To comply with your initial registration requirements, you must report within 72 hours of your release from
prison, placement on probation, parole or supervised release or entry into the State of Georgia to the
appropriate Sheriff’s Office of the county where you reside.
|
||C.|If you are released from prisonfor another offenseduring the time that you are required to registerfor a
sex offense,then you must notify the Sheriff of the county where you last registered within 72 hours after
such release.
|
||D.|You must provide street or route address for your place of residence. A post office box does not constitute
an address. If you are homeless, you must provide a description of the place you sleep.
|
||E.|If the place of residence is a motor vehicle or trailer, provide the vehicle identification number, the license
tag number, and a description, including color/ color scheme, of the motor vehicle or trailer, and where the
motor vehicle or trailer is located.
|
||F.|If the place of residence is a mobile home, provide the mobile home location permit number, the name and
address of the owner of the home, a description including the color scheme of the mobile home and if
applicable, a description of where the mobile home is located on the property.
|
||G.|If the place of residence is a manufactured home, provide the name and address of the owner of the home, a
description including the color scheme of the manufactured home, and if applicable, a description of where
the manufactured home is located on the property.
|
||H.|If the place of residence is a vessel, live-aboard vessel, or houseboat, provide the hull identification number,
the manufacturer’s serial number, the name of the vessel, live –aboard vessel, or houseboat, the registration
number, and a description including color scheme of the vessel, or houseboat.
|
||I.|You must register all addresses.
|
||J.|You are required to register with the sheriff’s office of the county where you reside within 72 hours prior to
your birthday each year to be photographed and fingerprinted.
|
||K.|If you have been determined to be asexually dangerous predator, you will remain on the registry for
life and you must register with the sheriff of the county of residence 72 hours prior to your birthday each
year and 6 months following your birthday to update your registration information.
|
||L.
|You shall not intentionally photograph a minor without the consent of the minor’s parent or guardian.
|
||M.
|If you have been determined to be a sexually dangerous predator, you will be required to wear an
electronic monitoring system for the remainder of your life as well_as pay for the monitoring fee._
|
||N.
|If you are enrolled, employed or practice a vocation at an institution of higher education in this state, you
must provide the name, address, and county of each institution including each campus attended and your
position or enrollment status, as well as any change in enrollment, employment, or vocation status to the
sheriff.
|
||O.
|If you are homeless, you must register in person to the sheriff of the county where you sleep within 72 hours
after release from prison or placement on parole, supervised release probation or entry into this state and
provide the location where you are sleeping.
|
|
|
P.
|

If you are homeless, you must report in person to the sheriff of the county where you sleep within 72 hours
of changing your sleeping location.
|

IIG01-0001
Attachment 1

4/01/2011
# Georgia Sex Offender Registration Notification Form

|Initial|Provision|Col3|
|---|---|---|
|

|Q.
|If you are homeless, you must report in person to the sheriff of the county where you are registered
within 72 hours of changing your sleeping location, and to the sheriff of the county where you moved
your sleeping location within 72 hours of moving.
|
||R.
|If you change any of the required registration information, other than residence address, you must give
the new information to the sheriff of the county with whom you are registeredwithin 72 hours of the
change of information.
|
||S.
|Regardless if your new residence address is within your county or outside your county (even temporary),
you must give the new address to the sheriff of the county with whom you last registeredwithin 72 hours
prior to moving and to the sheriff of the county to which you are moving 72 hours prior to moving.
|
||T.
|You must register in any state where you are employed, volunteer, practice a vocation, or are a student.
|
||U.
|If you move to another state, you are required to report to the sheriff’s office you last registered with in
the State of Georgia within 72 hours prior to moving and to the designated law enforcement agency in
your new state of residence within 72 hours.
|
||V.
|You are subject to all registration requirements if you move to Georgia from any other place and are
required to register as a sex offender in another jurisdiction.
|
||W.
|Persons who are sentenced under the first offender act are subject to the registration requirements until
the offender successfully completes the requirements as set forth by the court.
|
||X.
|At this time, the laws concerning registration of sex offenders can be found in the Official Code of
Georgia Annotated, Section 42-1-12 through 42-1-19.
|
||Y.|You must meet certain criteria to petition the court for release from registration and/or
residency/employment restrictions. See O.C.G.A. § 42-1-19.
|
|Residency / Employment / Loitering Restrictions|Residency / Employment / Loitering Restrictions|Residency / Employment / Loitering Restrictions|
||Z.
|If your date of offense was committedprior to June 4, 2003, there are no residency or employment
restrictions, however, you must adhere to all registration requirements. {O.C.G.A. § 42-1-17}|
||AA.
|If your date of offense was committed betweenJune 4, 2003 – June 30, 2006,you cannot reside within
1,000 feet of any child care facility, school, or areas where minors congregate (public & private parks,
recreation facilities, playgrounds, skating rinks, neighborhood centers, gymnasiums, and similar facilities
providing programs or services directed towards persons under 18 years of age). {O.C.G.A. § 42-1-17}
|
||BB.
|If your date of offense was committed between July 1, 2006 – June 30, 2008,you cannot reside within
1,000 feet of any child care facility, church, school, areas where minors congregate (public & private
parks, recreation facilities, playgrounds, skating rinks, neighborhood centers, gymnasium, school bus
stops, and public & community swimming pools). {O.C.G.A. § 42-1-16}
|
||CC.
|If your date of offense was committed between July 1, 2006 – June 30, 2008,you cannot be employed
at any child care facility, church, school, or any business or entity that is located within 1,000 feet of said
location. {O.C.G.A. § 42-1-16}
|
||DD.
|If your date of offense was committed between July 1, 2006 – June 30, 2008,and you are a sexually
dangerous predator, you cannot be employed at any child care facility, church, school, area where minors
congregate (public & private parks, recreation facilities, playgrounds, skating rinks, neighborhood
centers, gymnasium, school bus stops, and public & community swimming pools) or any business or
entity that is located within 1,000 feet of said location. {O.C.G.A. § 42-1-16}
|
||EE.
|If your date of offense was committed betweenJuly 1, 2006 – June 30, 2008,you cannot loiter at any
child care facility, school, or areas where minors congregate (public & private parks, recreation facilities,
playgrounds, skating rinks, neighborhood centers, gymnasium, school bus stops, and public &
community swimming pools). {O.C.G.A. § 42-1-16}|
||FF.|If your date of offense was committed on July 1, 2008 or after,you cannot reside within 1,000 feet of|

_Revised July 2010_

6

IIG01-0001
Attachment 1

4/01/2011
# Georgia Sex Offender Registration Notification Form

|Initial|Provision|Col3|
|---|---|---|
||GG.
|If your date of offense was committed on July 1, 2008 or after,you cannot be employed/volunteer at
any child care facility, church, school, or any business or entity that is located within 1,000 feet of said
location. {O.C.G.A. § 42-1-15} A volunteer is defined at O.C.G.A § 42-1-15 (a) (4).
|
||HH.
|If your date of offense was committed on July 1, 2008 or after,and you are a sexually dangerous
predator, you cannot be employed/volunteer at any child care facility, church, school, area where minors
congregate (public & private parks, recreation facilities, playgrounds, skating rinks, neighborhood
centers, gymnasium, school bus stops, public libraries, and public & community swimming pools) or any
business or entity that is located within 1,000 feet of said location. {O.C.G.A. § 42-1-15}
|
||II.
|If your date of offense was committed on July 1, 2008 or after,loitering is prohibited at any child care
facility, school, or areas where minors congregate (public & private parks, recreation facilities,
playgrounds, skating rinks, neighborhood centers, gymnasium, school bus stops, public libraries, and
public & community swimming pools). {O.C.G.A. § 42-1-15}
|
|Additional Information|Additional Information|Additional Information|
||JJ.|If you violate a sex offender statute, you may be found guilty of a felony and may be punished by
imprisonment for up to 30 years.
|
||KK.
|The current laws concerning sex offender registration can be found on the Georgia Secretary of State’s
website (www.legis.state.ga.us), the District Attorney’s Office, and many other places.
|
||LL.
|The Georgia legislature meets at least once each year, usually beginning in January, and each time the
legislature meets the laws concerning sex offender registration in Georgia can be changed. Most of those
changes take effect July 1; however, some changes take effect as soon as the legislation is signed by the
Governor.
|
||MM.
|It is_my duty_ to always be aware of the current law concerning my duty to register as a sex offender and I
understand that ignorance of the law is no excuse for my failure to abide by the laws concerning the
registration of sex offenders.
|
||NN.
|Every state in the United States has a sex offender registry; however, each state’s laws are different and
should I ever leave the State of Georgia, it is my duty to familiarize myself with the laws of the state
where I live. Ignorance of the law is no excuse for my failure to abide by the laws concerning the
registration of sex offenders in any state where I live.
|
||OO.
|If you are arrested on any charges, you must report in person to the sheriff’s office which you were last
registered immediately upon release to update your registration.
|
||PP.
|Under the Adam Walsh Child Protection and Safety Act of 2006, 18 United States Code § 2250, if you
fail to comply with registration requirements and are involved in interstate travel, you may be subject to
federal prosecution.|

I have read, or had read to me, this registration notification form and understand its contents.

____________________________________ ___________________________________
Offender’s Name (Print) Offender’s Signature

____________________________________ ___________________________________
Witness Name (Print) Witness Signature

_____________________________________ ___________________________________
Name of Witnessing Agency (Print) Telephone Number for Witnessing Agency

_The purpose of this form is to provide the necessary information for the registration of sexual offenders in the_
_State of Georgia. The information contained within this form is not intended to provide legal advice to any person_
_required to register as a sexual offender._

_Revised July 2010_

7

IIG01-0001
Attachment 1

4/01/2011
# Georgia Sex Offender Registration Notification Form THE PENALTY O.C.G.A. § 42-1-12

(n) Any individual who:

(1) Is required to register under this Code section and who fails to comply with the

requirements of this Code section;

(2) Provides false information; or

(3) Fails to respond directly to the sheriff of the county where he or she resides or sleeps

within 72 hours prior to such individual’s birthday shall be guilty of a felony and
shall be punished by imprisonment for not less than one nor more than 30 years;
provided, however, that upon the conviction of the second offense under this
subsection, the defendant shall be punished by imprisonment for not less than
five nor more than 30 years.

I have read, or had read to me, this registration notification form and understand its contents.

__________________________________ ___________________________________
Date Offender’s Name (Print)

___________________________________ ____________________________________
Offender’s Signature Offender’s Date of Birth

___________________________________ ___________________________________
Witness Name (Print) Witness Signature

___________________________________ ___________________________________
Name of Witnessing Agency (Print) Telephone Number for Witnessing Agency

_Revised July 2010_ 7