PR OB 12C (SCD Rev. 2/05) United Stat es Distri ct C ourt for ___________________________________ Petit ion for War r ant or Sum mons for Offender Under Supervision Name of Offender: ____________________________________________ Case Number: ____________________ Name of Sentencing Judicial Officer: ______________________________________________________________ Date of Original Sentence: ______________________________________ Original Offense: ________________________________________________________________________ ______ ________________________________________________________________________ ____________________ ________________________________________________________________________ ____________________ ________________________________________________________________________ ____________________ Original Sentence: ______________________________________________________________ _______________ Type of Supervision: ____________________________ Date Supervision Commenced: _____________________ Assistant U.S. Attorney: ______________________________ Defense Attorney: ___________________________ PETITIONING THE COUR T G To issue a warrant G To issue a summons The probation officer believes that the offender has violated the following condition(s) of supervision: Violation Number Nature of Noncompliance American LegalNet, Inc. www.USCourtForms.com>>>> 2PR OB 12C (SCD Rev. 2/05) United Stat es Distri ct C ourt for ___________________________________ U.S. Probation Officer Recommendation: G The term of supervision should be G revoked. G extended for __________ years, for a total term of __________ years. G The condition of supervision should be modified as follows: I declare under penalty of perjury that the foregoing is true and correct. Executed on _________________________________ _________________________________ U.S. Probation Officer American LegalNet, Inc. www.USCourtForms.com>>>> 3PR OB 12C (SCD Rev. 2/05) United Stat es Distri ct C ourt for ___________________________________ THE COURT ORDERS: G No action. G The issuance of a warrant. G The issuance of a summons. G Other _________________________________________ Signature of Judicial Officer _________________________________________ Date American LegalNet, Inc. www.USCourtForms.com