EFTA00181819

Officer's Name:

For Month Ending: ___



STATE OF FLORIDA
DEPARTMENT OF CORRECTIONS
WRITTEN MONTHLY REPORT


YOUR NAME: Jill Epstein

DC#:

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

Mobile Home Park and Lot Number, if applicable):

358 cm Bull Way, Poh Paul 3348°

<font color="red">(Provide physical location – <u>NOT</u> Post Office Box)</font>

CELLULAR TELEPHONE No.

PAGER No. ___

Vehicle Make/Model/Year/Tag #: ___



EMPLOYER: FSF



SUPERVISOR'S NAME:



EMPLOYER'S ADDRESS:



250 Amorito Am



EMPLOYER'S TELEPHONE No.



CELLULAR TELEPHONE No.__

PAGER No. ___



EMPLOYER EMAIL:



YOUR TOTAL MONEY EARNED MONTHLY:

$$+10,000$$  (Gross Amount)

Full time Part-time Hours Worked

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

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

Have you used or bought illegal drugs or controlled substances?

health, drug, alcohol, therapy, or self-improvement programs?

Have you attended educational, vocational classes or mental

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: ___

Official Use Only:

Signature of Officer Receiving Report:

Date WMR Received: ___

| Date WMR Due: | 10-6-09 |

| :--- | :--- |

| Comments: | --- |

8:10Am

I certify the above to be true and complete:

Your Signature:

Mailing Address:

City: John Bond



State: FC Zip: 33480



E-Mail Address: ___

(if applicable)

DC3-268 (Revised 6-01)