Monthly Supervision Report (MSR)

Personal Information *This question is required.

First Name *This question is required.

Last Name *This question is required.

Email Address *This question is required.

DOB *This question is required.

Phone Number *This question is required.

Date of Appointment *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Street Address *This question is required.

City *This question is required.

State *This question is required.

Zip Code *This question is required.

Own or Rent *This question is required.

Names of Adults Living with you *This question is required.

Did you move during the month? *This question is required.

Please enter an 'other' value for this selection.

Vehicle Information *This question is required.

Year
Make & Model
Color
Plate Number & State
Owner

Did you get any new Identifying Marks *This question is required.

Please enter an 'other' value for this selection.

Employment Information *This question is required.

Name of Employer *This question is required.

Street Address *This question is required.

City *This question is required.

State *This question is required.

Zip Code *This question is required.

Phone Number *This question is required.

Your Title / Position *This question is required.

Is your employer aware of your criminal status *This question is required.

Name of Supervisor *This question is required.

Did you miss any days of work during the last month? *This question is required.

Please enter an 'other' value for this selection.

Hourly Wages *This question is required.

Current Work Schedule *This question is required.

Did you change jobs? *This question is required.

Were you terminated? *This question is required.

If you changed jobs or were terminated, state when & why.

Monthly Financial Statement *This question is required.

Net Earnings from Employment (Amount after taxes)
Other Cash Inflows (Child support, SSI, Disablility)
	Total : 0

Are you past due on any of the following fines? *This question is required.

Space Cell	Yes	No	N/A
Court Fees/Fines	Court Fees/Fines: Yes	Court Fees/Fines: No	Court Fees/Fines: N/A
Probation Fees	Probation Fees: Yes	Probation Fees: No	Probation Fees: N/A
Restitution	Restitution: Yes	Restitution: No	Restitution: N/A

Provide explanation for past due fees

Do you have any additional court ordered financial obligations not listed above such as alimony, child support, etc.? *This question is required.

Please enter an 'other' value for this selection.

Compliance With Conditions of Supervision During the Past Month *This question is required.

Were you questioned by any law enforcement officers

Please enter an 'other' value for this selection.

Were you arrested or named as a defendant in any criminal case *This question is required.

Please enter an 'other' value for this selection.

Were any pending charges disposed of during the month *This question is required.

Please enter an 'other' value for this selection.

Was anyone in your household arrested or questioned by law enforcement *This question is required.

Please enter an 'other' value for this selection.

Did you possess or have access to a firearm *This question is required.

Please enter an 'other' value for this selection.

Did you possess or use any illegal drugs *This question is required.

Please enter an 'other' value for this selection.

Did you travel outside Lea County without permission *This question is required.

Please enter an 'other' value for this selection.

Were you ordered to install an ignition interlock? *This question is required.

If yes please answer the following questions

Install Date
Have you been locked out due to breath test? If yes, how many times?

Did you have community service work to perform *This question is required.

If yes, please answer the following questions

Number of hours completed this month
Number of hours missed this month
Balance of hours remaining

Do you have drug, alcohol or mental health aftercare? *This question is required.

If yes, did you miss any sessions during this month?

Did you fail to respond to any Text Message and/or Voice Mail instructions? *This question is required.

Please enter an 'other' value for this selection.

1. Probation DocumentsPlease attach any documentation you wish to submit to your officer. (Pay stubs, proof of enrollment or completion, any other requested documents)

File: {{filename}} delete

WARNING: ANY FALSE STATEMENTS MAY RESULT IN A VIOLATION OF YOUR PROBATION AND MAY LEAD TO ADDITIONAL INCARCERATION AND/OR RECOVATION.

2. BY SIGNING THIS DOCUMENT I CERTIFY THAT ALL INFORMATION FURNISHED IS COMPLETE AND CORRECT. *This question is required.

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