DIRECTIONS FOR COMPLETING THE MONTHLY SUPERVISION REPORT FORM
This monthly form is to be completed at the end of each month and received by the Probation
Office no later than the 5th day of the following month. The mailing of the monthly report
is a privilege. If you repeatedly fail to meet the deadline, you may be required to deliver the
monthly report in person to your Probation Officer. The form must be completed thoroughly
and accurately. Do not hesitate to discuss this form with your Probation Officer if you have
any questions about its completion. If something does not apply specifically to you, write
NOT APPLICABLE in the block. Do not leave any lines blank. All entries should be neatly printed and legible.
1. Print your first, last, and middle name.
2. Print any other name that may have been used in this Court.
3. Print your full street address and apartment number. DO NOT PUT P.O. BOX OR
MAIL DROP NUMBERS IN THIS SPACE. If you live on the 1st, 2nd, or 3rd floor,
list this location.
4. Print your city, state and zip code.
5. Print the name of your apartment complex and/or community subdivision. Advise
as to whether you rent or own the property.
6. This is where you may list your P.O. Box number or any other mailing address.
7. Print all phone numbers including the following: pagers, cellular phones, message
numbers (a number you may be reached at or a phone where a message can be
conveyed to you), and/or answering services.
8. List all names of persons living at your residence.
9. Check YES or NO if you moved during the month.
10. Print the exact date of your move and your reason for moving. THE PROBATION
OFFICER MUST BE PERSONALLY NOTIFIED TEN DAYS PRIOR TO
ANY CHANGE IN RESIDENCE.
11. Print the NAME, ADDRESS, AND PHONE NUMBER of your employer. If self
employed, list your office address, phone number, and name of company.
12. Print the name of your immediate supervisor and his phone extension.
13. Check YES or NO as to employers’ knowledge of your criminal status.
14. Print the number of days missed from work and the specific reason for the absence.
15. Print your exact job title.
16. List the gross income which is your total income before deductions.
17. Print the EXACT days and hours that you report to and leave from work (DO NOT
WRITE 40 HOURS). If your shift varies, supply your Probation Officer with a copy
of your weekly work schedule.
18. Check YES or NO if you had a job change or were terminated during the month.
THE PROBATION OFFICER MUST BE PERSONALLY ADVISED TEN
DAYS PRIOR TO ANY CHANGE IN EMPLOYMENT.
19. Print an exact date of termination and reason why you were terminated from the
20. List all vehicles owned or driven by you. Print the year, make, model, color of the
vehicle, license plate number, and name of the owner. This must be completed every
month. This also includes company vehicles you may drive.
21. List the amount of income you bring home after deductions.
22. List any additional monies or benefits which you receive during the month such as
food stamps, welfare, inheritance, loans, trust funds, spouse’s income, or other.
23. Add up your net income plus any other income and write in the amount.
24. The total of all expenses incurred goes here.
25. List all debts which are past due and the amount you owe for each debt.
26. Check here whether or not you have a checking account and list the name of the bank
and your account number. Indicate whether this is an individual or joint account and
list who is on the signature card. List your EXACT balance at the end of the month.
Your probation Officer may request copies of bank statements in order to verify this
27. Do the same as #26 in regards to your savings account.
28. List all purchases of goods or services for which you paid $500.00 or more during the
month. Print the amount of purchase, date, description of the item or items, and the
method used for payment. If you used a credit card, list which card was used.
29. If you were questioned by law enforcement, check YES. Otherwise, check NO. If
yes, provide the exact date of the questioning, the title(s) of who questioned you, the
name(s) of the officer(s), the name of the agency, and the reason for the questioning.
YOU MUST ALSO PERSONALLY NOTIFY YOUR PROBATION OFFICER
IMMEDIATELY OF THIS CONTACT (attach copies of citations, bond papers,
complaints, or other documents for verification).
30. If you were arrested or named as a defendant in any other case, check YES.
Otherwise, check NO. If you, give the details, including the date of the charges and
the disposition or status of the case (attach documentation).
31. If you resolved any pending charges this month, check YES. Otherwise, check NO.
If yes, indicate the exact date of the hearing, the Court which you attended and the
final disposition of the case (attach a copy of the citation, receipt, charges, and
32. Was anyone in your household arrested or questioned by law enforcement during this
month? If you check YES, state what relation he/she is to you, his/her full name, and
the reason for the arrest or questioning. Advise your Probation Officer as to the
disposition or status of the case. Otherwise, check NO. If you were a victim in the
case, attach a copy of the police report.
33. If you had contact with anyone who has a criminal record, check YES and list his/her
full name. Otherwise, check NO.
34. If you possessed or had any access to a firearm, check YES and explain. Otherwise,
35. If you possessed or used any illegal drugs, check YES and explain when and what
type of drug. Otherwise, check NO.
36. If you traveled outside the District without the permission of the Probation Officer,
check YES and explain when and where you went. Otherwise, check NO.
37. If you owe money for a special assessment, restitution or fine with regard to your
case, check YES. Otherwise, check NO. If you check yes, list the amount you paid
during the month. NOTE: ALL PAYMENTS ARE TO BE MADE BY MONEY
ORDER (POSTAL OR BANK) OR CASHIER’S CHECK ONLY.
38. If you have community service work to perform, check YES. Otherwise, check NO.
If you check yes, list the number of hours you completed this month, the number of
hours you missed and the balance of hours that are remaining.
39. If you have drug, alcohol or mental health aftercare as a condition of your
supervision, check YES. Otherwise, check NO. If you check yes, note if you missed
any sessions during the month or if you failed to respond to phone recorder
instructions. If you check yes to either question, explain why you either missed a
session or failed to respond to the phone recorder instructions.
40. Sign and date your written monthly report certifying that all the information you
furnished is complete and correct.
NOTE: According to 18 U.S.C. § 1001, false statements on a written monthly report are
considered law violations and not technical violations. Any false statements may result in
revocation of probation, supervised release or parole, in addition to 5 years imprisonment,
a $250,000 fine or both.