Work Release / Home Monitoring Program Employer'S Affidavit Form

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CHELAN COUNTY REGIONAL JUSTICE CENTER
WORK RELEASE / HOME MONITORING PROGRAM
EMPLOYER’S AFFIDAVIT
Employee’s Name _________________________
Business Owner ___________________________
Applicant’s Supervisor ______________________
Business Name
__________________________
Business address __________________________
Additional Supervisor ______________________
Business City
__________________________
Additional Supervisor ______________________
Business License # _________________________
Business Phone ___________________________
Shop Address _____________________________
Job site __________________________________
I am the employer (or am authorized to make this Affidavit on behalf of the employer) of the above named
Work Release / Home Monitoring Applicant. This employee works for me as follows:
Applicant’s Work Schedule
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Applicant Begins Work at this
Time
Applicant Ends Work at this
Time
I also understand that changes in the above schedule must be kept to an absolute minimum. Changes, if
necessary, must not exceed the 16 hour maximum. (Call 667-6615, if no one answers, leave a message. If
the employee is on Work Release and the schedule change is being made after hours or on a weekend, call
the Jail at 667-6622 ) I understand the participant is to be at his/her authorized work site only, and that any
changes in that work site must be called in to the Work Release/Home Monitoring Staff.
I pay this employee by  ___ Check ___ Cash / each ___ week ___month ___ other _________________
** Note: Application cannot be processed without a rate of pay. RATE OF PAY IS: $________ .
I agree to notify the Chelan County Jail Program Staff at 667-6615 of the following (regarding the Work
Release/Home Monitoring Participant):
1. Absence from Work
5. Lay Off
2. Tardiness
6. Use of Alcohol / Drugs
3. Deviation from Work Schedule
7. Attempts to remove any home monitoring device.
4. Termination
8. Any other concerns or questions
Employer’s Signature ___________________________ Additional Supervisor_____________________
Date_____/______/__________
** FAX to 667-6620 Home Monitoring and Work Release Office
415 Washington St. Room 203 Wenatchee, Wa. 98801
Revised 09/2013

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