Monthly Report Form Lake County
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1
2MONTHLY REPORT FORM
Lake County Probation Department
201 South Smith St.
Lakeport, CA 95453
(707) 262-4285
Instructions: Print clearly. Answer all questions, do not leave blanks. Do not write “Same as last report” or “See last report.”
st
th
Do not send a copy. Report is due between the 1
and 10
of each month. DO NOT FAX REPORT. Do not send multiple
reports in one month, only the current month will count. Do not send dirty or soiled forms, and write legibly. Information
provided on this form is for the previous month.
DATE FORM COMPLETED: ______________________________
Who do you live with? (Do not list yourself. If you need more room print on back of form)
Full Name (s)
Age
Relationship to you
What is your source of monthly income (aid, employment, etc.)? _____________________________________________
If you are employed, who is your employer? ___________________________________ Full time
Part time
Name and phone number of your supervisor? ______________________________________________________
Employment address (including city and state)_____________________________________________________
EARNINGS
MONTHLY EXPENSES
What new debts do you have?
Monthly Salary:
Rent:
Food:
_______________________________
_______________________________
Spouse’s Salary:
Installment Payments:
Other income:
Insurance:
Explain other income:__________
Transportation:
Have you made your fine/restitution
payment this month?
Yes
No
Medical:
If no, explain why: ______________
Total Income:
Clothing:
Balance on hand:
Total Paid Out:
Have you had any police contact? Yes
No
If yes, explain ________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________
_____________________________
PRINT Name Here
SIGN Name Here
______________________________
_____________________________
Street address
Mailing Address
______________________________
______________________________
City, State
Zip code
City, State
Zip code
______________________________
New address? Yes
No
Date moved:_________________
Email Address
________________________(Is this a cell
)
# Yes
No
Phone Number
__________________________
CHECK HERE IF YOU NEED MORE FORMS
Cell Phone Provider
-- *DO NOT WRITE BELOW THIS LINE* --------- Office Use Only ---------- *DO NOT WRITE BELOW THIS LINE* --
Employee initial __________
PR _______________ C
CK M
FS?
Yes
No
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