CUI (when filled in)

Prescribed by: DoDI 1325.07

VICTIM/WITNESS CERTIFICATION AND ELECTION CONCERNING PRISONER STATUS

PRIVACY ACT STATEMENT

AUTHORITY: 42 U.S.C. 10607 et seq.; 18 U.S.C. 1512 et seq; DoDI 1325.07; DoDI 1030.2; and DoDD 1030.1.
PRINCIPAL PURPOSES: To inform victims and witnesses of their post-trial rights; to determine whether the victim or witness of a crime elects to
be notified of changes in the confinement status of a convicted criminal offender; and to record the election by the victim or witness of their desire to
be notified about subsequent changes in prisoner status.
ROUTINE USES: None.
DISCLOSURE: Voluntary; however, failure to provide identifying information will prevent the correctional facility from notifying victim or witness of
changes in a criminal offender's status.

SECTION 1 - ADMINISTRATIVE INFORMATION

Incident Number

Installation City State Zip Code

Court-martial case of United States v. ,

Print Name of Accused (Last, First, Middle Initial) Social Security Number (last 4 only)

Convened by ,
Court-Martial Convening Order Number, Date, and Issuing Command

SECTION 2 - CERTIFICATION OF NO VICTIM(S) OR WITNESS(ES)

I certify that this case does not involve a victim or witness entitled to receive information about the confinement status of the defendant
as required by 42 U.S.C. 10607 et seq., and U.S.C. 3771 et seq.

Date (YYYYMMDD) Signature of Trial Counsel or Designee Type Name (Last, First, Middle Initial)

Grade and Title Telephone Number (Include area code)

IF THERE ARE NO VICTIM(S) OR WITNESS(ES), STOP HERE AND SKIP TO SECTION 4.

SECTION 3 - CERTIFICATION OF ADVICE TO VICTIM(S) AND WITNESS(ES)

I certify that on this date I personally notified the victim(s) and witness(es) in the above-named court-martial case that included a
sentence to confinement, of their right under 42 U.S.C. 10607 et seq., and U.S.C. 3771 et seq., to receive information about the
status of the prisoner named in Section 1 of this form, to include length of sentence, anticipated earliest release date, likely place of
confinement, the possibility of transfer, and the right to receive notification of a new place of confinement. I advised of the possibility
of parole or clemency with an explanation of these terms. Additionally, I advised of the right to prior notification of the prisoner's
parole hearings, release from confinement, escape and death. I advised the victim(s) and witness(es) that to receive notification of
the prisoner's transfer, parole hearings, and release confinement, the victim or witness MUST PROVIDE THE INFORMATION
REQUIRED ON PAGE 2 OF THIS FORM. I advised all victim(s) and witness(es) that if they elect to terminate or reinitiate
notifications, or if they change their address, they must contact the Military Service Central Repository listed in Section 4. When a
Victim or Witness is not present to initial box 4 (on page 2 of this form) the Trial Counsel or Designee shall contact the Victim or
Witness in order to determine their election choice (Yes or No). Once verified, the Trial Counsel or Designee shall initial box 4
indicating and validating the Victim's or Witness's election choice.

Date (YYYYMMDD) Signature of Trial Counsel or Designee Type Name (Last, First, Middle Initial)

Grade and Title Telephone Number (Include area code)

SECTION 4 - DISTRIBUTION
1. MILITARY SERVICE CENTRAL 2. LAW ENFORCEMENT/SPECIAL 3. CORRECTIONAL FACILITY
REPOSITORY INVESTIGATION

DD FORM 2704, MAR 2013 Controlled by: OUSD(P&R) Page 1 of 3

CUI (when filled in) CUI Category: PRVCY
PREVIOUS EDITION IS OBSOLETE. LDC: FEDCON
POC: [email protected]
Prescribed by: DoDI 1325.07
CUI (when filled in)

SECTION 5 - LIST OF VICTIM(S) AND WITNESS(ES)

VICTIM/WITNESS CERTIFICATION AND ELECTION CONCERNING PRISONER STATUS

Court-martial case of United States v.

Print Name of Accused (Last, First, Middle Initial) SSSN - (last 4 only)

STATEMENT OF UNDERSTANDING: The victim(s) and witness(es) that have elected to receive information about changes in the status
of the prisoner are required to notify the respective Military Central Repository with an accurate address and telephone number to continue
receiving notifications on the prisoner's status, if their relocation results in changes to their address and/or telephone numbers.
STATEMENT OF TRANSFER NOTIFICATION: This transfer notification only applies in the event the above named prisoner is
permanently transferred to another Federal, State or local law enforcement agency or correctional facility. The victim(s) and witness(es)
will be notified using the address on file by DD Form 2705 of the prisoner's new location. The receiving Federal, State, or local agency will
be responsible for all further notifications to the victim(s) and witness(es) about the prisoner's status. The military correctional facility
retains responsibility for clemency board notifications.

INSTRUCTIONS: LIST ALL VICTIMS AND WITNESSES INVOLVED IN THE CASE. Using the drop-down box, indicate whether Adult, Parent,
Legal Guardian, Minor/Age, Incompetent, Incapacitated. If under 18 years old, incompetent or incapacitated, also list parent or legal guardian's name. Using
the next drop-down box, indicate whether victim (V), witness (W), or victim and witness (V&W). For all minor victims/witnesses, ensure minor status and age
(at time of CM) are identified after their full name in Column 1. All minors, incapacitated and incompetent persons require a competent adult to be notified on
their behalf by placing an adult and minor victim in the same row. Individuals that elect to be notified of prisoner status changes initial the "Yes" block in
Column 4; otherwise initial the "No" block adjacent the respective name. The Trial Counsel or Designee (TC/D) are required to enter their initials in the Yes or
No box in Column 4 for unavailable victims or witnesses.

2. 3. 4.
1.
ADDRESS - Street, Apartment No., City, State, TELEPHONE NUMBER
NAME - Last, First, Middle Initial/AFFILIATION/STATUS (Include Area Code) (If under NOTIFY
ZIP Code 18 years old, incompetent or
(Select affiliation and status from drop-down lists.) (Initial)
(If under 18 years old, incompetent or incapacitated, incapacitated, also list Parent
(Provide age if Victim/Witness is a minor.) (List Parent or Guardian if
also list Parent or Legal Guardian's address, if different or Legal Guardian's number, if
Victim/Witness is under 18 or incompetent or incapacitated.)
from victim/witness) different from victim/witness) YES NO

TC/D:

TC/D:

TC/D:

TC/D:

TC/D:

TC/D:

TC/D:

TC/D:

TC/D:

TC/D:

DD FORM 2704, MAR 2013 Page 2 of 3

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.
Prescribed by: DoDI 1325.07
CUI (when filled in)

INSTRUCTIONS FOR COMPLETING DD FORM 2704,

VICTIM/WITNESS CERTIFICATION AND ELECTION CONCERNING PRISONER STATUS

PURPOSE: This form shall be used for victims and appropriate witnesses (those who fear harm by the offender) to elect to be notified of changes in the
offender's status while in confinement. For all cases resulting in a sentence to confinement, the DD Form 2704 shall be completed and forwarded to the
Service Central Repository, the gaining confinement facility, local responsible official, and the victim or witness, if any.

SECTION 1 - ADMINISTRATIVE INFORMATION

Incident Number: Obtained from the DD Form 1569.

Installation, City, State and Zip Code: The geographical location of the Convening Authority (CA).
Court-Martial Case of United States v.: Add the offender's name and last four digits of his/her Social Security number.
Convened By: Add the court-martial convening order number, date, and issuing command.

SECTION 2 - CERTIFICATION OF NO VICTIM(S) OR WITNESS(ES)

Complete this section only if there are no victims or witnesses who are entitled to notification under the Victim's Rights and Restitution Act of 1990, and
DoD Instruction 1030.2.
Date and Signature certifying there are no victim(s) or witness(es) who are entitled to notification under the Victim's Rights and Restitution Act of 1990,
and DoD Instruction 1030.2.
Print Name (Last, First, Middle Initial), Grade, Title and Telephone Number. Add the same identification as the individual signing the form.
If there are no victims or witnesses involved in this case, stop and go to Section 4.
Forward Page 1 only to the respective Military Central Repository.

SECTION 3 - CERTIFICATION OF ADVICE TO VICTIM(S) AND WITNESS(ES)

Complete this section, print, date and sign, certifying the victim(s) and/or witness(es) have been advised of their rights to be notified by the person signing
this document.
Date and Signature certifying that any victim(s) or witness(es) have been advised of their rights to notification under the Victim's Rights and Restitution
Act of 1990, and DoD Instruction 1030.2. The authorized signature per DoDI 1030.2 is the "Trial Counsel or Designee" as identified by Service specific
regulations.
Print Name (Last, First, Middle Initial), Grade, Title and Telephone Number. Add the same identification as the individual signing the form.
When a victim or witness is not present to initial box 4 (on Page 2 of this form), the certifying official of this document shall contact the Victim or
Witness in order to determine their election choice (Yes or No). Once verified, the certifying official shall initial box 4 indicating and validating
the Victim's or Witness's election choice.
Forward Page 1 and all other pages listing victims and witnesses to the Military Central Repository.

SECTION 4 - DISTRIBUTION

A copy of the completed form shall be forwarded to each of the listed agencies.
Block 1 - Military Service Central Repository. Add the address for the offender's branch affiliation.
Block 2 - Law Enforcement/Special Investigation. Add the address for the offender's branch affiliation.
Block 3 - Correctional Facility. Add the location of the prisoner's confinement.

SECTION 5 - LIST OF VICTIM(S) AND WITNESS(ES)

Statement of Understanding should be read to the victim(s) and witness(es) when possible.
Statement of Transfer Notification should be read to the victim(s) and witness(es) when possible.
Column 1. Add the identified victim(s) and witness(es). Provide age if victim/witness is a minor. Indicate whether Adult, Parent, Legal Guardian, Minor,
Incompetent, Incapacitated. If under 18 years old, incompetent or incapacitated, also list parent or legal guardian's name. Indicate whether victim (V),
witness (W), or victim and witness (V&W) in this case.
Column 2. Add the address of the identified victim(s) and witness(es). If under 18 years old, incompetent or incapacitated, also list parent or legal
guardian's address (if different from that of victim or witness).
Column 3. Add the complete telephone number of the identified victim(s) and witness(es). If under 18 years old, incompetent or incapacitated, also list
parent or legal guardian's telephone number (if different from that of victim or witness).
Column 4. Victim, witness, or Trial Counsel or Designee are required to enter initials in the Yes or No column, indicating desire to be notified
regarding the prisoner's status.
NOTE: Prevent victim(s) and witness(es) personal information from being released to other victim(s) and witness(es).
NOTE: DO NOT provide this form to the prisoner. This form (when filled in) is FOIA and PA exempt from release under DoD 5400.7R and 5 U.S.C.

TERMS AND DEFINITIONS

Victim: A person who has suffered direct physical, emotional, or pecuniary harm as a result of the commission of a crime committed in violation of the
UCMJ (Chapter 47 of the U.S.C., reference (b)) or in violation of the law of another jurisdiction if any portion of the investigation is conducted primarily by
the DoD Components. Refer to DoDD 1030.1, Enclosure 1, E1.1.5. - E1.1.5.4. for the list of individuals included as victims. When Victim is under 18
years of age, the term includes Parent, etc. (loco parentis precedence) and are afforded the same notification status as the victim due to the minor victim
relationship. Ensure their loco parentis title, e.g., Parent, is completed after their name in Column 1.

Witness: A person who has information or evidence about a crime, and provides that knowledge to a DoD Component about an offense in the
investigative jurisdiction of a DoD Component. When the victim is a minor, that term includes a family member or legal guardian.
THE TERM "WITNESS" DOES NOT INCLUDE A DEFENSE WITNESS OR AN INDIVIDUAL INVOLVED IN THE CRIME AS A PERPETRATOR OR
ACCOMPLICE. Further state - when the parent or guardian are crime witnesses for which the accused is found guilty and ordered a confinement
sentence (witnessed charges), in addition of being afforded the Victim status for the notification of a minor, as a parent/guardian, they are also afforded
the Witness status - annotate as (V & W). Those parent(s)/legal guardians of minors who assume the Victim status for notification purposes but did not
witness or provide evidence of the crime only assume the Witness status.

DD FORM 2704, MAR 2013 Page 3 of 3

CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.