Monthly Report Form - Yamhill County
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1YAMHILL COUNTY
MAIL OR GIVE TO YOUR
AND
PAROLE/PROBATION
STATE OF OREGON
OFFICER
ANY STATEMENTS MADE BELOW WHICH ARE LATER
FOUND TO BE UNTRUE MIGHT RESULT IN YOUR BEING DECLARED A VIOLATOR.
_________________________________________________________________
____________________________________________
Print Name
Date
_________________________________________________________________
Client’s Signature
THE FOLLOWING INFORMATION IS FOR ________________________, 19 _____
FOR ________________________________________________
Month
Probation/Parole Officer’s Name
1. EMPLOYMENT/INCOME ___________________________________________
2. EDUCATION/TRAINING
Employer __________________________________________________________
__ Attending College
Address
__________________________________________________________
__ GED Classes
Phone
________________ Name of Supervisor _________________________
__ Vocational Training
Job Duties ___________________________________________________________
Where _____________________________________
Days Worked During Month _______ Work Hours ________ Rate of Pay $_______
____________________________________________
Net Income for Month $_______________ How Many Others Do You Support ____
Source of Funding ____________________________
Other Income $___________ Source _____________________________________
____________________________________________
3. ACTIVITIES
Were you contacted by the police, arrested, jailed, cited and/or appeared in court during this month? __ Yes __ No.
If yes, explain what for, when, where, and why on back of this report.
If not working or attending school, how do you spend your spare time? ________________________________________________________________________
Did you travel during the month? ___ Yes ___ No If yes, where? ___________________________________________________________________________
4.
WHERE YOU WERE PLACED ON PROBATION/PAROLE, CERTAIN CONDITIONS WERE PLACED ON YOU. IF ANY OF THE FOLLOWING
ARE CHECKED AND/OR APPLY TO YOU, THEN YOU MUST FURNISH THE APPROPRIATE INFORMATION!
Attending alcohol/drug/therapy ___ Yes ___ No
You were ordered to pay
Where __________________________________________
Amount Paid
Balance
Last Payment
Counselor _______________________________________
__ Restitution
___________
_________
___________
Date last attended _________________________________
__ Fine
___________
_________
___________
Taking monitored antabuse
___ Yes ___ No
__ Attorney Fees
___________
_________
___________
Pharmacy _______________________________________
__ Probation Fees
___________
_________
___________
Dosage _________________________________________
Community Service
Comments _______________________________________
__ Complete
___ Not complete, ______ Balance to be completed
________________________________________________
________________________________________________
5. FINANCIAL
6. TRANSPORTATION
Balance on debts $___________________________________
Do you have a valid license? ___ Yes ___ No
Amount paid during month $___________________________
Driver’s license number __________________________________
Cash on hand $___________ Amount in savings $__________
Source of transportation ___ bus ___ car ___ other
Amount in checking $________________________________
If car: 1. Make _______________ 2. Make __________________
Paying child support? ____ Yes ___ No
Model _________________ ____
Model __________________
Monthly payment $__________________________________
Year ______________________
Year ___________________
Are you current? ___ Yes ___ No
Color ______________________
Color ___________________
If behind, how long? _________________________________
License No. _________________
License No. ______________
7.
PRESENT LIVING SITUATION
___ House ___ Apartment ___ Other _____________________________________________________________________________________________________
I am ___ Renting ___ Leasing ___ Boarding ___ Buying ___ Other
With whom do you live? ______________________________________________
Relationship ___________________________________________________
Current Address _____________________________________________________
Mailing Address (if different) _____________________________________
City ___________________________ State _______________________ ______
City _________________________ State ___________________________
Zip _____________________ Phone ___________________________________
Zip ___________________ Phone ________________________________
MCMINNVILLE, OREGON (503) 434-7513
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