Adult Monthly Reporting Form

Adult Monthly Reporting Form
BUTTE COUNTY PROBATION DEPARTMENT
ADULT DIVISION – MONTHLY REPORT FORM (MRF)
REPORT FOR THE MONTH OF: __________________________________
MY PROBATION OFFICER IS:____________________________________
(DATE STAMP HERE)
INSTRUCTIONS:
1.
PLEASE PRINT NEATLY. PROVIDE ALL INFORMATION REQUESTED. CHECK ALL BOXES THAT APPLY.
NAME:
TELEPHONE
(
)
FIRST, MIDDLE, AND LAST NAME
2.
RESIDENCE ADDRESS:
3.
MAILING ADDRESS (if different from residence address):
4.
PLEASE LIST EVERY PERSON WHO LIVES WITH YOU (List additional people on reverse side):
(Where you live)
Name:
•
Age:
Is this person on probation or parole? YES
NO
•
Age:
Is this person on probation or parole? YES
NO
•
Age:
Is this person on probation or parole? YES
NO
•
Age:
Is this person on probation or parole? YES
NO
Name:
Name:
Name:
5.
INCLUDE: STREET NUMBER & NAME, ANY APARTMENT OR SPACE NUMBER, CITY, STATE, AND ZIP CODE
Relationship to you
Relationship to you
Relationship to you
Relationship to you
WHAT IS YOUR SOURCE OF INCOME? (Check all that apply)
EMPLOYMENT
PENSION
OTHER
SELF-EMPLOYED
SPOUSE’S INCOME
PUBLIC ASSISTANCE (Welfare)
STUDENT LOANS/GRANTS
WORKMAN’S COMPENSATION
PARENTS
SSI
SSD
(Please Describe):
5.a. IF EMPLOYED, What type of work do you do?
6.
•
Your employer’s name and telephone no.
•
What days & hours do you work?
What is your hourly wage?
$
HAVE YOU HAD ANY LAW ENFORCEMENT CONTACT SINCE YOU LAST REPORTED TO PROBATION?
YES
NO
Which law enforcement agency?
If YES, When(date):
Were you arrested or did you receive a Notice to Appear?
YES
NO
If YES, please explain (use back of form
if necessary):
7.
8.
ARE YOU CURRENTLY ON A CUSTODY ALTERNATIVE PROGRAM, Such as SWAP, ESP, Parole?
YES
NO
7.a.
Do you have a jail “turn in” date? YES
ESP
NO
Sheriff’s Parole
If YES, what is the date?
REGISTRATION: Are you required to REGISTER as a NARCOTICS, ARSON, OR SEX OFFENDER?
YES
9.
If YES, which program? SWAP
(If YES, circle the category that applies, above) NO
Is your registration current?
YES
NO
COUNSELING/TREATMENT PROGRAMS:
Are you currently participating/attending a counseling/treatment program? YES
•
If YES please check which program(s): ADS
Child Abuse
Sex Offender
ReVia
EAP
Domestic Violence
NO
Anger Management
SB-38/DUI School
Other:
10.
ARE YOU ATTENDING AA or NA MEETINGS? YES
11.
ARE YOU TAKING ANY PRESCRIPTION MEDICATIONS? YES
12.
ARE YOU CURRENT WITH YOUR FINE AND/OR RESTITUTION PAYMENTS? YES
13.
) NO
(Number of times each week?
12.a.
Date last payment made:
12.b.
If you are not current with payments, PLEASE EXPLAIN:
PLEASE SIGN HERE:
NO
If YES, please list on back of form.
NO
DATE:
Please mail this report (and any other requested logs or documentation) at the beginning of every month or as otherwise
directed by your Probation Officer. If you need additional Monthly Report Forms, you may pick them up at the Butte County
Probation Department or check the box below and they will be sent to you at the mailing address that you have listed above.
Please note that any changes in address or contacts with law enforcement need to be reported immediately.
MAIL THIS REPORT TO:
BUTTE COUNTY PROBATION DEPARTMENT
42 County Center Drive
Oroville, CA 95965
PLEASE SEND ME MORE MONTHLY REPORT FORMS
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