Microsoft word - monthly report.doc

YAMHILL COUNTY
MAIL OR GIVE TO YOUR
PAROLE/PROBATION
STATE OF OREGON
ANY STATEMENTS MADE BELOW WHICH ARE LATER FOUND TO BE UNTRUE MIGHT RESULT IN YOUR BEING DECLARED A VIOLATOR. _________________________________________________________________ ____________________________________________ _________________________________________________________________ Client’s Signature THE FOLLOWING INFORMATION IS FOR ________________________, 19 _____ FOR ________________________________________________ 1. EMPLOYMENT/INCOME ___________________________________________ Employer __________________________________________________________ Address __________________________________________________________ Phone ________________ Name of Supervisor _________________________ Job Duties ___________________________________________________________ Where _____________________________________ Days Worked During Month _______ Work Hours ________ Rate of Pay $_______ ____________________________________________ Net Income for Month $_______________ How Many Others Do You Support ____ Source of Funding ____________________________ Other Income $___________ Source _____________________________________ ____________________________________________ 3. ACTIVITIES Were you contacted by the police, arrested, jailed, cited and/or appeared in court during this month? __ Yes __ No. If yes, explain what for, when, where, and why on back of this report. If not working or attending school, how do you spend your spare time? ________________________________________________________________________ Did you travel during the month? ___ Yes ___ No If yes, where? ___________________________________________________________________________ WHERE YOU WERE PLACED ON PROBATION/PAROLE, CERTAIN CONDITIONS WERE PLACED ON YOU. IF ANY OF THE FOLLOWING
ARE CHECKED AND/OR APPLY TO YOU, THEN YOU MUST FURNISH THE APPROPRIATE INFORMATION!
Attending alcohol/drug/therapy ___ Yes ___ No Where __________________________________________ Counselor _______________________________________ Date last attended _________________________________ Taking monitored antabuse ___ Yes ___ No Pharmacy _______________________________________ __ Probation Fees ___________ _________ ___________ Dosage _________________________________________ Comments _______________________________________ __ Complete ___ Not complete, ______ Balance to be completed ________________________________________________ ________________________________________________ Balance on debts $___________________________________ Do you have a valid license? ___ Yes ___ No Amount paid during month $___________________________ Driver’s license number __________________________________ Cash on hand $___________ Amount in savings $__________ Source of transportation ___ bus ___ car ___ other Amount in checking $________________________________ If car: 1. Make _______________ 2. Make __________________ Model _________________ ____ Model __________________ Monthly payment $__________________________________ Year ______________________ Year ___________________ Color ______________________ Color ___________________ If behind, how long? _________________________________ License No. _________________ License No. ______________ ___ House ___ Apartment ___ Other _____________________________________________________________________________________________________ I am ___ Renting ___ Leasing ___ Boarding ___ Buying ___ Other With whom do you live? ______________________________________________ Relationship ___________________________________________________ Current Address _____________________________________________________ Mailing Address (if different) _____________________________________ City ___________________________ State _______________________ ______ City _________________________ State ___________________________ Zip _____________________ Phone ___________________________________ Zip ___________________ Phone ________________________________ MCMINNVILLE, OREGON (503) 434-7513

Source: http://www.co.yamhill.or.us/sites/default/files/monthly_report.pdf