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            STATE V. ______________ ______ JUDICIAL DISTRICT COURT

            DOCKET # __________       PARISH OF ___________________

            DIVISION ______     STATE OF LOUISIANA

Notification to Sex Offender

            In accordance with La. Rev. Stat. 15:543, this court has the duty to provide _______________________ (name of offender) with the information necessary for awareness of sex offender and child predator registration and notification requirements. _______________________ has pled guilty to, been found guilty of, or been adjudicated delinquent of a violation of Title 14, Section ____ Subsection ____ of the Louisiana Revised Statutes of 1950. This crime of conviction or adjudication is:

            ( ) Under La. Rev. Stat. 15:541, defined as an aggravated offense or, with regard to offenders adjudicated as juveniles, an offense listed in La. Rev. Stat. 15:542(A)(3) which, pursuant to La. Rev. Stat. 15:544(B)(2)(a) or (b), requires lifetime registration and notification under Chapter 3-B of Title 15 of the Louisiana Revised Statutes of 1950.

            ( ) A second conviction for an offense requiring registration and notification under the provisions of Chapter 3-B of Title 15 of the Louisiana Revised Statutes of 1950 which, pursuant to La. Rev. Stat. 15:544(B)(2)(c), requires lifetime registration and notification under Chapter 3-B of Title 15 of the Louisiana Revised Statutes of 1950.

            ( ) Under La. Rev. Stat. 15:541, defined as a sexual offense against a victim who is a minor which, pursuant to La. Rev. Stat. 15:544(B)(1), requires 25 years of registration and notification under Chapter 3-B of Title 15 of the Louisiana Revised Statutes of 1950.

            ( ) Is defined neither as an aggravated offense nor a sexual offense against a victim who is a minor under La. Rev. Stat. 15:541 which, pursuant to La. Rev. Stat. 15:544(A), requires 15 years of registration and notification under Chapter 3-B of Title 15 of the Louisiana Revised Statutes of 1950.

The above registration and notification periods shall begin to toll from the date you are released from prison, from the date of being placed on parole, supervised release or probation, or from the date of your conviction, if you are not sentenced to a term of imprisonment or jail. Additionally, you have been convicted of:

            ( ) An aggravated offense as defined in La. Rev. Stat. 15:541, you must update your registration, in person, every ninety days from the date of initial registration, with the appropriate law enforcement agencies as provided in La. Rev. Stat. 15:542.

            ( ) A sexual offense involving a victim who is a minor as defined in La. Rev. Stat. 15:541, you must update your registration, in person, every six months from the date of initial registration, with the appropriate law enforcement agencies as provided in La. Rev. Stat. 15:542.

            ( ) An offense not defined in La. Rev. Stat. 15:541 as an aggravated offense or a sexual offense involving a victim who is a minor, you must update your registration, in person, annually from the date of initial registration, with the appropriate law enforcement agencies as provided in La. Rev. Stat. 15:542.

            Based on the foregoing, you are hereby notified of the following:

            (1) That you, within three (3) business days of establishing residence in Louisiana or if a current resident, within three (3) business days after conviction or adjudication if not immediately incarcerated or taken into custody, or within three (3) business days after release from confinement, shall obtain and provide the following information to each sheriff or police department in accordance with La. Rev. Stat. 15:542(B) (except in Orleans Parish where registration shall take place with the New Orleans Police Department):

            (a) Name and any aliases used by you.

            (b) Physical address or addresses of residence.

            (c) Name and physical address of place of employment. If you do not have a fixed place of employment, you shall provide information with as much specificity as possible regarding the places where you work, including but not limited to travel routes used by you.

            (d) Name and physical address of the school in which you are a student.

            (e) Two forms of proof of residence for each residential address provided, including but not limited to a driver’s license, bill for utility service, and bill for telephone service. If those forms of proof of residence are not available, you may provide an affidavit of an adult resident living at the same address. The affidavit shall certify that the affiant understands his obligation to provide written notice pursuant to La. Rev. Stat. 15:542.1.4 to the appropriate law enforcement agency with whom you last registered when you no longer reside at the residence provided in the affidavit.

            (f) The crime for which you were convicted and the date and place of such conviction, and if known by you, the court in which the conviction was obtained, the docket number of the case, the specific statute under which you were convicted, and the sentence imposed.

            (g) A current photograph, fingerprints, palm prints, and a DNA sample.

            (h) Telephone numbers, including fixed location phone and mobile phone numbers assigned to you or associated with your residence address.

            (i) A description of every motorized vehicle registered to or operated by you, including license plate number and vehicle identification number, and a copy of your driver’s license and identification card. This information should always be provided before the vehicle is operated and, if the vehicle is registered to you, no more than three days after the vehicle is registered, even if it has not yet been operated.

            (j) Social security number and date of birth.

            (k) A description of your physical characteristics, including but not limited to sex, race, hair color, eye color, height, age, weight, scars, tattoos, or other identifying marks on your body.

            (l) Every e-mail address, online screen name, or other online identity used by you to communicate on the Internet.

            (m)(i) Temporary lodging information regarding any place where you plan to stay for seven or more days and the length of the stay. This information shall be provided at least three days prior to the date of departure unless an emergency situation has prevented the timely disclosure of the information.

            (ii) Temporary lodging information regarding international travel shall be provided regardless of the number of days or nights you plan to stay. This information shall be provided at least twenty-one days prior to the date of departure unless an emergency situation has prevented the timely disclosure of the information. Upon receipt of this information by the bureau from the law enforcement agency, this information shall then be sent by the bureau to the United States Marshals Service’s National Sex Offender Targeting Center for transmission to the proper authorities.

            (n) Travel and immigration documents, including but not limited to passports and documents establishing immigration status.

            (o) A state sex offender identification card from the office of motor vehicles.

            (2) You shall register with the sheriff and police chief in each parish and municipality where you maintain your residence(s) and with the sheriff of the parish in which you are employed and attend school in accordance with La. Rev. Stat. 15:542. For initial registration only, you, if you are not immediately taken into physical custody, shall register on the date of conviction or adjudication with the sheriff in the parish of your conviction or adjudication in accordance with La. Rev. Stat. 15:542. If you live, work, or attend school in Orleans Parish, however, you shall register with the New Orleans Police Department and not with the sheriff of that parish.

            (3) If you are incarcerated as a result of the crime, you shall provide all information listed in Paragraph (1) of this Section to the Department of Public Safety and Corrections, or if a juvenile, to the office of juvenile justice, within ten (10) days prior to release from confinement. You shall still appear in person at the sheriff’s office within three (3) business days of release from confinement. You shall register with the sheriff of the parish in which the residence address you initially supplied to the department is located, unless the residence has changed and you have registered with the sheriff of the parish in which the new residence address is located.

            (4) During the declaration of an emergency, if you enter an emergency shelter you shall, within the first twenty-four (24) hours of admittance, notify the management of the facility, the chief of police of the municipality, and the sheriff of the parish in which the shelter is located of your sex offender status in accordance with La. Rev. Stat. 15:543.2.

            (5) You have a duty to provide notice of change of address or other registration information to the sheriff of the parish of residence within three business days. If the new or additional residence is located in a different parish, then you must register with the sheriff of the parish in which the new or additional residence is located. You shall also send written notice within three business days of re-registering in the new parish to the sheriff of the parish of former registration in accordance with La. Rev. Stat. 15:542.1.2. If the new address is situated within a municipality, you must also register with the police department of that municipality within three business days of establishing the residence.

            (6) You shall give notice of the crime for which you were convicted, your name, address, a physical description, and a photograph to the following in accordance with La. Rev. Stat. 15:542.1:

            (a) At least one person in every residence or business within a one-mile radius in a rural area and a three-tenths of a mile radius in an urban or suburban area of the address of the residence where you will reside upon release, including all adult residents of your residence.

            (b) The superintendent of the school district where you will reside.

            (c) The lessor, landlord, or owner of the residence or the property on which you reside.

            (d) The superintendent of the park, playground, and recreation districts within the designated area where you will reside only if the victim was under eighteen (18) years of age at the time of the commission of the offense.

            *Any person convicted of a violation of La. Rev. Stat. 14:89 shall not have to include a photograph in the notice described in Paragraph (6).

            *Juveniles adjudicated for a crime requiring registration DO NOT have to provide this community notice.

            (7) In accordance with La. Rev. Stat. 15:542.1, community notification shall be given by mail within twenty-one days of the date of conviction, if you are not taken into custody at the time of conviction, and within twenty-one days of the date of release from confinement if sentenced to a term of imprisonment. This notification shall also occur within twenty-one days of each time you change residence within twenty-one days of establishing residency in the new locale. This notification shall also occur at least every five years, whether or not you change residences. This notification shall occur in each jurisdiction in which you regularly reside.

            *Juveniles adjudicated for a crime requiring registration DO NOT have to provide this community notice.

            (8) In accordance with La. Rev. Stat. 15:542.1, community notice shall be published on two (2) separate days within this period in the official journal of the governing authority of the parish where you plan to reside, unless ordered to be published in a different journal or newspaper by the sheriff or local ordinance.

            *Those convicted of La. Rev. Stat. 14:92(A)(7) are not required to publish notice in the newspaper or official journal as provided in Paragraph (8).

            *Juveniles who are adjudicated for a crime requiring registration DO NOT have to provide this community notice.

            (9) In accordance with La. Rev. Stat. 15:542.1(B), an offender who provides recreational instruction to persons under the age of seventeen (17) shall post a notice in the building or facility where such instruction is being given. This notice shall contain your name and photograph, the date and jurisdiction of conviction, and the crime for which you were convicted.

            (10) In accordance with La. Rev. Stat. 15:542(C)(2), you must, within ten (10) days prior to release from a correctional facility, provide a photograph and all other required registration information to the Department of Public Safety and Corrections, or if a juvenile, to the office of juvenile justice for purposes of the State Sex Offender and Child Predator Registry. Providing false information during this process constitutes failure to register exposing you to prosecution and the penalties detailed at the end of this document. The address provided to the Department of Public Safety and Corrections through this process shall be presumed to be your residence address. In accordance with La. Rev. Stat. 15:542(C)(2), you must register with the sheriff of the parish in which this address is located within three business days of your release from confinement, whether or not you actually establish a residence there, unless you establish a residence elsewhere AND register with that jurisdiction within three business days of your release from confinement. Failure to do so is a violation of the registration statutes and will subject you to prosecution under La. Rev. Stat. 15:542.1.4.

            (11) In accordance with La. Rev. Stat. 15:542.1.2, if you change your place of residence or establish a new or additional residence, you shall appear in person at the office of the sheriff of your parish of residence where you are currently registered within three (3) business days of the change to register the new address. If the new address is located in a different parish, then you shall also appear in person at the office of the sheriff of your new parish of residence within the same time period. If your parish of residence is in Orleans Parish, then the registration shall take place at the New Orleans Police Department and not with the Orleans Parish Sheriff.

            (12) In accordance with La. Rev. Stat. 15:542.1.2, if you are absent from your current address of registration for more than thirty (30) consecutive days or an aggregate of thirty (30) days or more in a calendar year, and are physically present at another address during that same period of time, you shall register in person the new address as one of your addresses of residence. If the new address is in a parish different from your current address, you shall also register in person with the sheriff of the new parish within three (3) business days of the tolling of the time periods listed. This requirement notwithstanding, you shall still notify the sheriff of one of your parishes of residence in person if you are to take up temporary lodging for seven (7) or more days. It is only after the thirty-day limit is exceeded that the new registration shall occur.

            (13) You shall also appear in person at the office of the sheriff of any of your parishes of residence when there is a change in your name, place of employment, or enrollment. This appearance shall occur within three (3) business days of the change. If your address of residence is in Orleans Parish, this registration update shall take place at the New Orleans Police Department and not with the Orleans Parish Sheriff’s Office.

            (14) You shall be prohibited from certain types of employment in accordance with La. Rev. Stat. 15:553 for the duration of the registration period. A copy of this statute is provided to you with this notification.

            (15) In accordance with La. Rev. Stat. 15:542(C), you shall update your registration annually on the anniversary of the initial registration by appearing in person at the office of each law enforcement agency with which you are required to register and shall pay an annual registration fee of sixty dollars ($60.00).

            (16) Failure to comply with any of these registration and notification requirements is a felony for which you shall be punished by a fine of up to one thousand dollars ($1,000.00) and imprisonment at hard labor for not less than two years nor more than ten years without benefit of parole, probation, or suspension of sentence. Upon a second or subsequent conviction, you shall be punished by a fine of up to three thousand dollars ($3,000.00) and imprisonment at hard labor for not less than five years, nor more than twenty years without benefit of parole, probation, or suspension of sentence.

            (17) For those offenders who have been convicted of a sex offense as defined in La. Rev. Stat. 15:541 involving a victim who was under the age of thirteen (13) at the time of the offense, La. Rev. Stat. 14:91.2 is applicable which prohibits such offenders from residing or being present in certain locations. A copy of this statute is provided to you with this notification.

            (18) For those offenders who have been convicted of La. Rev. Stat. 14:81 (indecent behavior with juveniles), La. Rev. Stat. 14:81.1 (pornography involving juveniles), La. Rev. Stat. 14:81.3 (computer-aided solicitation of a minor), or La. Rev. Stat. 14:283 (video voyeurism) or have been convicted of a sex offense as defined in La. Rev. Stat. 15:541 in which the victim of the sex offense was a minor, La. Rev. Stat. 14:91.5, which prohibits such offenders from using certain social networking websites, is applicable. A copy of this statute is provided to you with this notification.

            THUS DONE AND SIGNED this ____ day of _____________, 20___ in open court, in_____________, Louisiana.

                                                                                    ______________________________

                                                                                    Judge, ____ Judicial District Court

            I hereby certify that the above requirements have been explained to me, that I have received a copy of the above notice of sex offender registration and notification requirements, and a copy of the statutes providing for such requirements. I also understand that I will be subject to any changes made by the legislature to the registration laws from this day forward.

____________________________

(Name of Sex Offender)

____________________________

Defense Counsel Signature

            Acts 2006, No. 175, §1; Acts 2007, No. 460, §2, eff. Jan. 1, 2008; Acts 2008, No. 816, §1; Acts 2009, No. 205, §2; Acts 2010, No. 973, §1, eff. July 6, 2010; Acts 2012, No. 50, §1; Acts 2012, No. 205, §2; Acts 2013, No. 408, §1; Acts 2016, No. 562, §1.