Personal Information Información Personal Last Name Apellido(s) First Name Nombre(s) Middle Name Segundo Nombre SID # numero de identification estatal Date of Birth Fecha de nacimiento Probation/Parole Officer’s Name Oficial de supervisión - Select -Abernethy, TiffanyAnderson, EricBradeen, IsabelaBredahl, JuliannaCloyes, DanelleCokeley, KeithCossey, DanielCowan, RenaeDelk, MeghanDennis, AmandaDrews, ErinDUII TeamEdge, NikiElmer, TrishErne, AmberERSU UnitGeiger, BenjaminGraham, JenniferHafner, KelseyHolstad, BeauJett, MatthewKays, StephenKerns, KharaLoftis, ErinMyers, GregPacheco, GretchenPaldi, MerinPankratz, MelissaPringle, MarneRickles, MichelleRidgeway, JasonRipley, ChristineRSU TeamSherman, AndrewShirey, SusanSilva, JordynTaylor, BrentWhite, JasonWilson, Tyree Report is for the month ofEl reporte es para el mes de Report is for the month ofEl reporte es para el mes de: Month MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Report is for the month ofEl reporte es para el mes de: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Address Home Address Domicilio Apt/Space CityCiudad StateEstado - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIPCódigo postal Mailing Address Mailing Address (if different)Dirección de correo (si es diferente) Apt/Space CityCiudad StateEstado - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIPCódigo postal Do other people live with you?¿Con quién vive? Yes/Si No/No Person List the names and relationship of each person living with you. Haz una lista de los nombres y la relación de cada persona que vive contigo. Are any on supervision?¿Está bajo supervisión? Yes/Si No/No What are their PO’s names and the counties they are supervised out of? Home Phone Teléfono Work Phone Número de trabajo Cell Phone Celular Message Phone Mensajes Email Correo electrónico VehicleVehículo Year Año Year: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Vehicle Make/Model Modelo/Marca Color Color License Plate # Placa # State Estado - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Employment/EducationEmpleo/Educación Are you working or in school?¿Estas trabajando o yendo a la escuela? Yes/Si No/No Days and HoursDias laborales/Horas) Contact Contact NameNombre del supervisor Employer/SchoolEmpleo/Escuela EmailCorreo electrónico PhoneTeléfono AddressDomicilio CityCiudad StateEstado - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIPCódigo postal Monthly Income Ingreso mensual If not working, how are you financially supported? Si no está trabajando, ¿cómo se está manteniendo financialmente? Law Enforcement ContactContacto con la Policía Did you have any law enforcement contact?¿Tuvo contacto con la policía? Yes/Si No/No Date Fecha Location Lugar Explain Explique Did you appear in court?¿Se presentó en corte? Yes/Si No/No Date Fecha Location Lugar Explain Explique Treatment/ConditionsTratamiento/Condiciones Are you in treatment?¿Está asistiendo tratamiento? Yes/Sí No/No Agency(s) La agencia Counselor(s) Consejero/a Are you taking prescribed medications?¿Está tomando un medicamento recetado? Yes/Sí No/No Please list all medications Anote los medicamentos Are you attending weekly support groups?¿Está asistiendo grupos de apoyo? Yes/Sí No/No Are you doing community service? ¿Está haciendo servicio comunitario? Yes/Sí No/No Date last worked El ultimo día trabajado Hours remaining Horas que faltan Did you pay court fees/fines?¿Hizo un pago a la corte? Yes/Sí No/No Amount Paid Cuanto Pago Date Paid Fecha Did you pay supervision fees?¿Hizo un pago de supervisión? Yes/Sí No/No Amount Paid Cuanto Pago Date Paid Fecha I hereby certify that all statements made on this online form are true and complete. I understand that any statements made that are later found to be untrue may result in a violation hearing or imposition of structured sanctions. Yo afirmo que lo de arriba es verdadero y correcto. Yo entiendo que cualquier declaración que he hecho que después se descubre ser falsa pueda resultar en una audiencia de violación o una imposición de sanciones estructuradas. Submit
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