EFTA00181821

Officer’s Name: ___
For Month Ending: ___
Date/Time submitted:___

# STATE OF FLORIDA
DEPARTMENT OF CORRECTIONS
WRITTEN MONTHLY REPORT

YOUR NAME:  Tell Eastern DC#:

YOUR RESIDENCE ADDRESS: *(include Name of*

Subdivision, Apartment Complex and Number,

Mobile Home Park and Lot Number, if applicable):

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

(If yes, circle which one)

(Provide physical location - NOT Post Office Box)

PAGER No. ___

TELEPHONE No.



EMPLOYER: FSF



Vehicle Make/Model/Year/Tag #: ___

CELLULAR TELEPHONE No.

SUPERVISOR'S NAME: INDYKC.



EMPLOYER'S ADDRESS:





25 = Australian



EMPLOYER'S TELEPHONE No.

CELLULAR TELEPHONE No.__

PAGER No. ___

**EMPLOYER EMAIL:** ___

YOUR TOTAL MONEY EARNED MONTHLY:

$$ \$ 910,000 $ (Gross Amount)



Full time___ Part-time___ Hours Worked___



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 used or bought illegal drugs or controlled substances?

Have you attended educational, vocational classes or mental

(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!

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

Signature of Officer Receiving Report:

Official Use Only:

Date WMR Received: ___

Date WMR Due: ___

I certify the above to be true and complete:

Your Signature: ___

Mailing Address: 358 13-111.

City: No Black

State: FL Zip: 33490

E-Mail Address: ___