Monthly Reporting Form

YAKIMA COUNTY DISTRICT COURT
PROBATION SERVICES

MONTHLY REPORTING FORM/
DEFERRED PROSECUTION

This report is due by the 15th day of each month. If this report is not received by that date, a violation may be filed with the Court. If you submit your report electronically, please call before the 15th to verify that your form has been received.

Print Completed Form


Select the type of report being submitted: Monthly
Case Manager:			Reporting Month/Year
Name:			Date of Birth:
E-mail Address:
Mailing Address:
Street	City	State	Zip	Is this a new address: Yes No
Is this were you live? Yes No If no, what is your physical address?
Street	City	State	Zip

Phone:			Message Phone:
Employer:			Phone:
Are you current with your Probation fee payments? Yes No
If not current please contact Heather Sides to make payment arrangements at 574-1879.

Are you complying with your Court ordered alcohol/drug, domestic violence, or any other Court ordered treatment? Yes No
Treatment Agency			Counselor:
Last scheduled session			Next scheduled session

Have you been arrested/cited since the last report? Yes No
If yes, please explain:
Have you consumed alcohol since your last monthly report? Yes No
Have you consumed illegal drugs since your last monthly report? Yes No
Do you have a valid driver's license? Yes No

This report must be filled out completely and correctly to be valid. Failure to do so will be considered a violation of your Probation.
Questions or Comments:
	By checking the box to the left, I hereby certify or affirm under penalty of perjury of the laws of the State of Washington that the foregoing is true.		Date:
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