PROBATION AND COURT SERVICES REPORT FORM

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Probation Officer  (Choose One):  

1.  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:

2. Are you working (Type Yes or No): If "No", go to 2A
 
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:

2A.  Unemployment supported by (Type in: Public aid , Unemployment comp. , Family , or Friends):
 

3.  
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:


4.  Are your fines, costs or restitution paid?  (Type Yes or No) (If "Yes", go to 5)
 

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

Amount Owed:
 

5.  
Are you attending counseling, treatment?  (Type Yes or No) (If "No", go to 5B)
 
 
Counseling/Treatment Agency:
Counselor's Name:


Last appointment (MM/DD/YY):
 

Next appointment (MM/DD/YY):
 

5B.  Are you attending A.A or N.A?  (Type Yes or No)  (If "No", go to 6)
 

How often?


6.  List any other special conditions ordered by the court:


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


7.
  Have you been ticketed, arrested, involved in an accident, or charged with any new offenses during the past 4 weeks?  (If "No" go to 8) 
 

If so, where?


For what?


When arrested or charged (MM/DD/YY):
 
Date you go to court (MM/DD/YY):
 

8.  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):

  

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