OPROB 8 Assigned U.S. Probation Officer: ______________________________________(Rev. 9/00) U.S. PROBATION OFFICE MONTHLY SUPERVISION REPORT F OR THE MONTH , 20 . Name: Court Name (if different): PART A: RESIDENCE (If new address, attach copy of lease/purchase agreement.) Street Address, Apt. Number: Own or Rent? Home Phone: Cellular Phone: Pager: City, State, Zip Code: Persons Living With You: Secondary Residence: Own or Rent? Did you move during the month? Yes No Mailing Address (if different): E-M ail Address: If yes, date moved: Reason for Moving: PA RT B: EMPLOYMENT (If unemployed, list source of support under Part D.) Name, Address, Phone No. of Employer: Name of Immediate Supervisor: Is your employer aware of your criminal status: Yes No How many days of work did you miss? Why? Position Held: Gross Wages: Normal Work Hours: Did you change jobs? Yes No If changed jobs or terminated, Were you terminated? Yes No state when and why: PART C : VEHIC LES (List all vehicles owned or driven by you.) 1. Year/Make/Model/Color: Mileage: Tag Number: Owner: Vehicle I.D.#: 2. Year/Make/Model/Color: Mileage: Tag Number: Owner: Vehicle I.D.#: PA RT D: MONTHLY FI NANCI AL S TAT EMENT Net Earnings from Employment: Do you rent or have access to: (Attach Proof of Earnings) a post office box? Yes No a safe deposit box? Yes No a storage space?YesNo Other Cash Inflows: Name and Address of Location: Box No. or Space TOTAL M ONTHLY CASH INFLOW S: TOTAL M ONTHLY CASH OUTFLOW S: Do you have checking Yes No Does your spouse, significant other, or dependant have a checking or savings Bank Name: account that you enjoy the benefits of or make occasional contributions Account Balance: toward? Do you have savings account(s)? Yes No Yes No Bank Name: Account Balance: Bank Name: Attach a complete listing of all other financial account information, if you have multiple accounts. Account No.: Balance: List all expenditures over $500 (including e.g., goods, services, or gambling losses) Date Amount Method of Payment Description of Item >>>> 2OPROB 8 Page 2(Rev. 9/00) PART E: COM PLIA NCE WITH CONDITIONS OF SUPERVI SION DURING THE PAS T MO NTH W ere you questioned by any law enforcement officers? W ere you arrested or named as a defendant in any criminal case? Yes No Yes No If yes, date: If yes, when and where? Agency: Charges: Reason: Disposition: (Attach copy of citation, receipt, charges, disposition, etc.) Were any pending charges disposed of during the month? Was anyone in your household arrested or questioned by law enforcement? Yes No Yes No If yes, date: If yes, whom? Court: Reason: Disposition: Disposition: Do you have any contact with anyone having a criminal record? Do you possess or have access to a firearm? Yes No Yes No If yes, whom? If yes, why? Did you possess or use any illegal drugs? Did you travel outside the district without permission? Yes No Yes No If yes, type of drug: If yes, when and where? Do you have a special assessment, restitution, or fine?Yes No If yes, amount paid during the month: Special Assessment: Restitution: Fine: NOTE: ALL PA YMENTS T O BE MADE B Y MONEY ORDER ( POS TAL OR BANK) OR CAS HIER S CHECK ONLY. Do you have community service work to perform? Do you have drug, alcohol, or mental health aftercare? Yes No Yes No Number of hours completed this month: If yes, did you miss any sessions during this month? Yes No Number of hours missed: Did you fail to respond to phone recorder instructions? Yes No Balance of hours remaining: If yes, why? WAR NI NG: ANY FA LS E S TA TEMENT S MAY RES ULT IN REV OCAT ION I CER TIFY T HAT AL L INFORMA TION FUR NISHE D IS C OMP LE TE OF P ROBA TI ON, SUP ERV ISED RE LEA SE , OR PA ROLE , IN ADDIT ION AND CORREC T. 5 YE ARS IMPR ISONMENT, A $250,000 FI NE, OR BOT H. (18 U.S.C. 1001) SIGNATURE DAT E REM ARKS: REC EI VE D: M ail OC HC CC RETU RN TO: U.S. Probation Thomas F. Eagleton U.S. Courthouse th 111 S. 10 Street, Suite 2.325 St. Louis, MO 63102 Fax: 314-244-6735 U.S. Probation Officer Date