EFTA00181812

Officer's Name:

For Month Ending: ___

# STATE OF FLORIDA
DEPARTMENT OF CORRECTIONS
WRITTEN MONTHLY REPORT

Date/Time submitted:___

Jeffrey Epstein

YOUR RESIDENCE ADDRESS: (include Name of Subdivision, Apartment Complex and Number, Mobile Home Park and Lot Number, if applicable):

358 El Brillo Way Palm Beach, FL 33480

(Provide physical location – **NOT** Post Office Box)

TELEPHONE No. 561-8000

CELLULAR TELEPHONE No. 501

PAGER No. ___

Vehicle Make/Model/Year/Tag #: ___

EMPLOYER: FSF

SUPERVISOR'S NAME: Darren Indyke

EMPLOYER'S ADDRESS:

250 S. Australian Ave Suite 1401 West Palm Beach, FL 33401

EMPLOYER'S TELEPHONE No.

CELLULAR TELEPHONE No.__

PAGER No. ___

EMPLOYER EMAIL: ___

YOUR TOTAL MONEY EARNED MONTHLY:

$$ 10K + \text{(Gross Amount)} $$

Full time Part-time Hours Worked Additional (2^{nd}) employment information: ___

Additional (2^{nd}}) employment information: ___

## List full names, ages, and your relationship to all persons who resided at your residence during this month:

Have you attended educational, vocational classes or mental health, drug, alcohol, therapy, or self-improvement programs?

(If yes, circle which one)

(If yes, circle which one)

Have you been arrested or had any contact with law enforcement during the last month?

If yes, explain what happened on separate sheet of paper, attached to report.

If you went into debt for any reason, explain: ___

If not working, give reason and source of income: ___

If you have any questions or problems to discuss with your Officer, explain:___

If monetary obligation owed, amount paid this month: $___

Receipts are available through your probation officer. DO NOT SUBMIT CASH OR PERSONAL CHECKS! Make money order payable to the Department of Corrections.

If monetary obligation owed and no payment made, give reason and date when payment will be made: ___

Signature of Officer Received

Official Use Only

RECEIVED

Date WMR Received: JAN 05 2010

Date WMR Due:

I certify the above to be true and complete:

Your Signature:

Mailing Address:

City: ___

State:___ Zip:___

E-Mail Address: ___

E-Man Address: ___

(if applicable)