Free Monthly Report - Nebraska

MONTHLY SUPERVISION REPORT U.S. Probation Office
111 SOUTH 18 th PLAZA , SUITE C79 OM AH A, NE 68102-1312 O FFICE (402) 661-7555 FA X (402) 661-7550 530 U.S. CO UR THOU SE 100 CEN TENN IAL M ALL N OR TH LINC O LN , N E 68508 O FFICE (402) 437-5223 FA X (402) 437-5654 332 U.S. CO UR THOU SE 300 EAST THIRD STREET N O R TH PLA TTE, N E 69101 O FFICE (308) 532-1918 FA X (308) 532-4212

Report for the month of: Name: Address:

Officer: Today's Date: New Address? Yes Q No Q Move in Date:

City:
Home Phone: ( ) -

State:
Cellular: ( ) -

Zip Code:
E-M AIL ADDRESS

List occupants staying at your residence.

Employer:
Address: Phone #:

Is this a new job? Yes Q No Q Is employer aware you are on supervision? Yes Q No Q Your job title: Start date:

Gross monthly pay:

Work days/hours:

Supervisor's name:

ALL QUESTIONS PERTAIN TO THE MONTH LISTED ABOVE (mark yes or no) Were you terminated from a job?

NO

YES

EXPLANATIONS IF YOU RESPONDED "YES"
W hen? W hy?

Any new vehicles in your household?

Year/make/model/color: License number: Owner:

Did you open any new checking or savings accounts? Do you have access to post office box, safe deposit box or storage space? Were you questioned/contacted/ticketed by any police officers? Were you arrested or named as a defendant in any criminal cases? Were any pending charges disposed of during the month? Was anyone in your household arrested or questioned by law enforcem ent?

Bank name: Account #: W here? Box # or space #: W hen/where/why?

W hen/where/why?

W hen/where?

W ho/when/where/why?

K M L June 2007

NO
Did you have any contact with anyone having a criminal record (other than at work, treatment or AA/NA)? DO YOU HAVE ACCESS TO OR DID YOU POSSESS A FIREARM ? DID YOU POSSESS OR USE ANY ILLEGAL DRUGS OR USE ALCOHOL? DID YOU M ISS ANY URINE/ALCOHOL-DRUG COLLECTIONS?

YES
Who/when/where/why?

[If yes, you will need to provide specific information to your officer] [If yes, an officer will contact you]

[If yes, an officer will contact you]

Are you taking any prescribed medications?

List medication and dosage:

Did you miss any treatment sessions? Did you travel outside the District without permission? DID YOU VIOLATE ANY OTHER CONDITIONS OF SUPERVISION, NOT PREVIOUSLY LISTED?

[If yes, an officer will contact you] W hen/where/why?

[If yes, an officer will contact you]

Did you report the violation to your USPO?
THE FOLLOW ING QUESTIONS PERTAIN TO THE M ONTH LISTED ON THE FIRST PAGE [fill in the amounts or if not applicable, put n/a] How many community service hours did you complete? W here? Contact person: How much did you pay on monies owed the Court? Special Assessment: Restitution: Did you pay any money on your Home Confinement debt? W hat was your gross pay from work for this month? List amounts received from any other sources of income. How much? W hat was your net income/take home pay? W hat was the source?

AMOUNT

How many hours? Phone #: Fine:

LIST ALL SINGLE ITEM EXPENDITURES OVER $500 INCLUDING PURCHASES OF GOODS OR SERVICES. Date Amount M ethod of payment Description of property, vehicle or item

WARNING: Any false statem ents on this report may result in revocation of probation, supervised release or parole! I CERTIFY THAT ALL INFORMATION FURNISHED IS COMPLETE AND CORRECT .

Name:

______________________________________________________________

Date:

**********

Received by: __________________________________

Date: ________________________

You can now report electronically on the Web! Go to www.ned.uscourts.gov Contact your officer for your PACTS number- This is the number U.S. Probation uses to identify you.
K M L June 2007