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: ___¶