Fillable Community Service Request Form printable pdf download

Community Service Request Form

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COMMUNITY SERVICE REQUEST

STATE OF FLORIDA

Case Number:_______________________

-Vs-

________________________________________

Citation Number:____________________

Defendant

I am requesting to do Community Service work in lieu of paying the fine/civil penalty imposed on the above listed

citation(s).

The reason for your financial hardship. Choose either “Yes” or “No” and answer the following questions:

I am unemployed:

Yes____ or No____

I work only Part Time:

Yes____ or No____

How many hours weekly ____________

I have a limited income:

Yes____ or No____

Monthly Gross Income $____________

I am a full time/part time student:

Yes____ or No____

Additional Remarks:

_____________________________________________________________________________________________

________________________________

____________________________________

Defendant’s Signature

Date

Name:__________________________________________________

Date Requested:______________________

Street Address: __________________________________________

City: __________________________ State:___________ Zip:______________

Phone Number: ____________________________

Date Defendant notified by mail:________________________ Date Community Service Notified: _____________

Date Approved: _________ Date Denied: _________ Hearing Officer Signature: ____________________________

You have requested that your traffic/misdemeanor fine be worked off by doing Community Service work. The

Hearing Officer has approved working off your fine(s) of $_____________ which converts to ____________ hours

of Community Service work to be completed by:_________________________(within 90 days).

You are directed to the Community Service Department of the Court Services located at 6816 Caroline Street

(Hwy 90), Milton, Florida (Gavin Purvis @ 623-0178). You will be required at that time to pay a $55.00 intake

fee for the program. You will be instructed when and where to do your community service work.

Upon completion of community service hours required, you will bring your completed “TIME SHEET” back to the

Community Service Department. You are then personally responsible for providing the Clerks’ office with the proof

from the Community Service Department/Probation Office of your completed community service hours.

Community Service Request Form

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