PR O B 12B (SC D Rev. 2/05) United States District Court for ___________________________________ Request for Modifying the Conditions or Term of Supervision with Consent of the Offender (Probation Form 49, Waiver of Hearing is Attached) Name of Offender: ____________________________________________ Case Number: ____________________ Name of Sentencing Judicial Officer: ______________________________________________________________ Date of Original Sentence: ______________________________________ Original Offense: ______________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Original Sentence: _____________________________________________________________________________ Type of Supervision: ____________________________ Date Supervision Commenced: _____________________ PETITIONING THE COURT G To extend the term of supervision for __________ years, for a total term of __________ years. G To modify the conditions of supervision as follows: American LegalNet, Inc. www.USCourtForms.com PR O B 12B (SC D Rev. 2/05) United States District Court for ___________________________________ CAUSE Respectfully submitted, by U.S. Probation Officer Date: American LegalNet, Inc. www.USCourtForms.com PR O B 12B (SC D Rev. 2/05) United States District Court for ___________________________________ THE COURT ORDERS: G No action. G The extension of supervision as noted above. G The modification of conditions as noted above. G Other _________________________________________ Signature of Judicial Officer _________________________________________ Date American LegalNet, Inc. www.USCourtForms.com