Caption
The district, United States of America v. the defendant, the case number and the sentencing date.
AO 249
Drug Offender's Reinstatement of Federal Benefits
AO 249, Drug Offender's Reinstatement of Federal Benefits, is a one-page order of a United States District Court. Under 21 U.S.C. §862(c), it reinstates a defendant's federal benefits that the court suspended on a conviction for the distribution or possession of a controlled substance. The U.S. Courts lists it under Expungement and Benefit Reinstatement Forms, effective on January 1, 2009, and the edition printed on the form is Rev. 01/09.
The order states that the defendant has completed a supervised drug rehabilitation program, tried in good faith to gain admission to one but could not because of its cost or inaccessibility, or has otherwise been rehabilitated. It is signed by the judge, and the clerk of court sends a copy to the U.S. Department of Justice.
It is a court document, not a form the defendant signs. This page explains the form in plain words and is not legal advice. You can fill it out free in your browser on this page and download the result without an account.

The district, United States of America v. the defendant, the case number and the sentencing date.
A statement that the defendant completed a supervised drug rehabilitation program, tried in good faith to gain admission but could not because of its cost or inaccessibility, or has otherwise been rehabilitated.
IT IS ORDERED that, under 21 U.S.C. §862(c), the defendant's federal benefits suspended by the court on a conviction for the distribution or possession of a controlled substance are reinstated.
The date and the judge's signature, printed name and title.
City and state of the defendant's residence, last four digits of the SSN, year of birth, and the clerk's mailing address for the Denial of Federal Benefits Program.
Enter the district, the defendant's name, the case number and the sentencing date.
The judge enters the date, signs, and prints a name and title.
Enter the city and state of the defendant's residence, the last four digits of the SSN and the year of birth. The form asks for no full SSN or full birth date.
The form says the clerk of court sends a copy to the Denial of Federal Benefits Program at the U.S. Department of Justice, Office of Justice Programs.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
AO 249 is an order of a United States District Court, signed by the judge.
U.S. Department of Justice - Office of Justice Programs, Attn: Denial of Federal Benefits Program, 810 Seventh Street, NW, Washington, D.C. 20531. The form says the clerk of court is responsible for sending it.
The form asks only for the last four digits of the SSN and the year of birth, along with the city and state of residence.
The form and its U.S. Courts page do not print a fee.
The order has a date line and the judge's signature, printed name and title below the IT IS ORDERED paragraph.
The order is captioned United States of America v. the defendant, and lists the defendant's city and state of residence, the last four digits of the SSN and the year of birth. The form has no signature line for the defendant.
The form says the clerk of court is responsible for sending a copy of the form to the U.S. Department of Justice, Office of Justice Programs.
The copy goes to the U.S. Department of Justice, Office of Justice Programs, Attn: Denial of Federal Benefits Program, at the address printed on the form.
The court completes and signs the order. These are the people the form names.
The agency’s own page for Form AO 249.
The official blank form, to print or fill by hand.
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The judge. The form has lines for the date and the judge's signature, printed name and title. It has no signature line for the defendant.
The form says that under 21 U.S.C. §862(c), the defendant's federal benefits suspended by the court on a conviction for the distribution or possession of a controlled substance are reinstated. The form does not list which benefits.
It states that the defendant has successfully completed a supervised drug rehabilitation program, or has in good faith tried to gain admission to one but was unable to because of its cost or inaccessibility, or has otherwise been rehabilitated.
The form says the clerk of court is responsible for sending a copy to the U.S. Department of Justice, Office of Justice Programs, Attn: Denial of Federal Benefits Program, 810 Seventh Street, NW, Washington, D.C. 20531.
No. It asks for the last four digits of the SSN, the year of birth, and the city and state of the defendant's residence.
No. The form and its U.S. Courts page do not print a fee.