Monthly Compliance Report Form - Washington Municipal Court
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13737 Pacific Highway East
Fife, Washington 98424
KEVIN G. RINGUS
(253) 922-6635
Municipal Court Judge
(253) 926-5435 - Fax
SALLY A. JACOBSEN
Municipal Court Administrator
Month ____________________________________________
MONTHLY COMPLIANCE REPORT FORM
This report shall not be considered as fulfillment of your reporting requirement unless completed in full.
Name ______________________________________________________ Home Phone______________________
Address ___________________________________________________ New Address Yes ____ No____
______________________________________________________________
Living With? ________________
Apt. #
City
Zip
Present Occupation _______________________________________________ Work Hours __________________
Employer _______________________________________________________ Work Phone __________________
Have you ever been arrested, cited, jailed or appeared in court since your last report?
No ____ Yes ____ Date_________________ Location ________________________________
Charge(s) __________________________________ Citation # __________________________________
Disposition ___________________________________________________________________________
When you were sentenced, the sentencing judge ordered you to complete certain conditions. Please indicate what
you are doing.
1. Attending Alcohol/Drug Program
Yes ____No ____ Give Dates __________
2. Taking Antabuse/Methadone
Yes ____No ____ Where _____________
3. Attending Therapy
Yes ____No____ Give Dates __________
4. Paying Fine
Yes ____No ____ Balance _____________
5. School or Training Program
Yes ____No ____ Name ______________
6. Seeking Employment
Yes ____No ____ Where _____________
7. Community Service Restitution
Hours Worked _________ Days ________
8. Paying Restitution
Yes ____No ____ Amount ____________
9. Monitoring Fees (if ordered)
Yes ____No ____ Amount ____________
10. Any Alcohol/Drug Use?
Yes ____No ____
11. Valid Driver’s License
Yes ____No ____
12. Liability Insurance
Yes ____No____
13. Driving
Yes ____No ____
14. Antabuse and/or AA Log Attached
Yes ____No ____
15. Is there anything you were ordered to do that you are not complying with?
Yes ____ No____
Explain:________________________________________________________________________________
______________________________________________________________________________________
If more forms are needed, please stop by the Court or make your own copies.
The proceeding statements are true and were answered to the best of my knowledge.
Signature: ______________________________________________ Date ________________________________
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