PROBATION AND COURT SERVICES REPORT FORM

Probation Officer (Choose One):*

Name:*

Phone*

Address*

City or Town*

State or Province*

Zip or Postal Code*

Who lives with you?

How long have you lived at this address?

Any move planned? (Type Yes or No)*

If so, when and where?

Do you own a vehicle? (Type Yes or No)*

Vehicle Year, Make, Model, Color

License plate number

Do you have a valid driver’s license? (Type Yes or No)*

Person vehicle is registered to

Are you working (Type Yes or No): If "No", go to 'Unemployment'*

Where are you employed?

Date Hired (MM/DD/YY)

Salary

Number of days worked in past 4 weeks?

Shift (Type 1st, 2nd, 3rd, Part-time)

Reason for any absence from work:

Unemployment supported by (Type in: Public aid , Unemployment comp. , Family , or Friends)*

Are you attending school? (Type Yes, No)*

School name:

What are you studying?

If you have received grade reports, been suspended or absent during the past 4 weeks, explain*

Are your fines, costs or restitution paid? (Type Yes or No) (If "Yes", go to 'Counseling')*

If no, Last Payment Date (MM/DD/YY)

Amount Owed

Are you attending counseling, treatment? (Type Yes or No) (If "No", go to 'A.A')*

Counseling/Treatment Agency

Counselor's Name

Last appointment (MM/DD/YY)

Next appointment (MM/DD/YY)

Are you attending A.A or N.A? (Type Yes or No) (If "No", go to 'Special Conditions')*

How often?

List any other special conditions ordered by the court*

Explain what you have done in the past 4 weeks toward fulfilling these conditions

Have you been ticketed, arrested, involved in an accident, or charged with any new offenses during the past 4 weeks? (If "No" go to 'Time Spent')*

If so, where?

For what?

When arrested or charged (MM/DD/YY)

Date you go to court (MM/DD/YY)

Who have you spent most of your time with the past 4 weeks?*

If you have any questions or concerns, submit with this form or call for an appointment. Questions or concerns

I certify the above information to be true and correct and I understand that any falsification of my answers is a violation of my court ordered Probation/Supervision. Signature:*

Today's Date (MM/DD/YY)*