Free Community Service Log - Nebraska

United States District Court
DISTRICT OF NEBRASKA
PROBATION OFFICE

JAMES P. ROWOLDT
CHIEF PROBATION OFFICER

111 SOUTH 18th PLAZA, SUITE C79 OMAHA, NE 68102-1312 COMM (402) 661-7555 FAX (402) 661-7550

MARY LEE RANHEIM
DEPUTY CHIEF PROBATION OFFICER

According to the conditions of your sentence, you are responsible for completing service. This form is to provide verification information of those hours.

hours of community

Name of agency_________________________________________________________________________ Date Number of Hours Worked Type of Work Completed Signature of Supervisor

I affirm that the information provided on this form is true and correct.

Signed:___________________________________________

Date:_____________________________

Additional space is provided on the back of this form. You are required to bring this form each time you visit your Probation Officer. Should you have any questions, please do not hesitate to contact your officer.

Date

Number of Hours Worked

Type of Work Completed

Signature of Supervisor