PROB 8 (Rev. 09/00) U.S. PROBATION OFFICE MONTHLY SUPERVISION REPORT FOR THE MONTH OF Name , 20 . Court Name (if different): PART A: RESIDENCE (If new address, attach copy of lease/purchase agreement) Street Address, Apt. Number: Own or Rent? City, State, Zip Code: Home Phone: Cellular Phone: Pager: Persons Living With You: Secondary Residence Own or Rent? Mailing Address (if different): E-Mail Address Did you move during the month? 9 Yes 9 No If yes, date moved: Reason for Moving: PART 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: 9 Yes 9 No How many days of work did you miss? _________________________________________________________________ Did you change jobs? Were you terminated? 9 Yes 9 Yes 9 No 9 No Position Held: Why? Gross Wages: Normal Work Hours: If changed jobs or terminated, state when and why: PART C: VEHICLES (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.#: PART D: MONTHLY FINANCIAL STATEMENT Do you rent or have access to: Net Earnings from Employment: (Attach Proof of Earnings) a post office box? 9 Yes 9 No a safe deposit box? a storage space? Other Cash Inflows: Name and Address of Location: 9 Yes 9 Yes 9 No 9 No Box No. or Space TOTAL MONTHLY CASH INFLOWS: TOTAL MONTHLY CASH OUTFLOWS: Do you have checking account(s)? 9 Yes 9 No Does your spouse, significant other, or dependant have a checking or savings account that you enjoy the benefits of or make occasional contributions toward? Bank Name: Account No: Do you have savings account(s)? 9 Yes Balance: 9 No Bank Name: Account No: Balance: Attach a complete listing of all other financial account information, if you have multiple accounts. List all expenditures over $500 (including e.g., goods, services, or gambling losses) Date Amount 9 Yes 9 No Bank Name: Account No: Method of Payment Balance: Description of Item 2002 © American LegalNet, Inc. PROB 8 (09/00) Page 2 PART E: COMPLIANCE WITH CONDITIONS OF SUPERVISION DURING THE PAST MONTH Were you questioned by any law enforcement officers? 9 Yes 9 No Were you arrested or named as a defendant in any criminal case? 9 Yes 9 No If yes, when and where? If yes, date: Charges: Agency: Disposition: Reason: (Attach copy of citation, receipt, charges, disposition, etc.) Were any pending charges disposed of during the month? 9 Yes 9 No Was anyone in your household arrested or questioned by law enforcement? 9 Yes 9 No If yes, date: If yes, whom? Court: Reason: Disposition: Disposition: Do you have any contact with anyone having a criminal record? 9 Yes 9 No Do you possess or have access to a firearm? 9 Yes 9 No If yes, whom? If yes, why? Did you possess or use any illegal drugs? 9 Yes 9 No Did you travel outside the district without permission? 9 Yes 9 No If yes, type of drug: If yes, when and where? Do you have a special assessment, restitution, or fine? 9 Yes Special Assessment: 9 No If yes, amount paid during the month: Restitution: Fine: NOTE: ALL PAYMENTS TO BE MADE BY MONEY ORDER (POSTAL OR BANK) OR CASHIER’S CHECK ONLY. Do you have community service work to perform? 9 Yes 9 No Do you have drug, alcohol, or mental health aftercare? 9 Yes 9 No Number of hours completed this month: If yes, did you miss any sessions during this month? 9 Yes 9 No Did you fail to respond to phone recorder instructions? 9 Yes 9 No Number of hours missed: Balance of hours remaining: If yes, why? WARNING: ANY FALSE STATEMENTS MAY RESULT IN REVOCATION OF PROBATION, SUPERVISED RELEASE, OR PAROLE, IN ADDITION TO 5 YEARS IMPRISONMENT, A $250,000 FINE, OR BOTH. I CERTIFY THAT ALL INFORMATION FURNISHED IS COMPLETE AND CORRECT. (18 U.S.C. § 1001) SIGNATURE REMARKS: DATE RECEIVED Mail OC HC CC RETURN TO: U.S. Probation Officer Date 2002 © American LegalNet, Inc. ____