Record Check Monthly Report Form

City Hall closed for Juneteenth

City Hall and other city facilities will be closed on Friday, June 19, for Juneteenth.

Travel Advisory: Lake Hills Boulevard Closure

Starting June 15, Lake Hills Boulevard is closed between 151st and 154th avenues Southeast for two months. Expect travel delays and avoid the area for non-essential travel, if possible. For the latest updates, detour maps and information on the project to reduce flooding in the area, visit Kelsey Creek Culvert.

Please complete and submit this form as directed by your supervising probation officer. Incomplete forms will not be accepted. Completed forms will be forwarded to your probation officer for review and an additional copy will be sent to the email address you have provided. For questions, please contact your probation officer directly.

Please note, completion of this form is intended for informational purposes. It is not a substitute for any required meetings you may have with your probation officer. Please coordinate any such meetings directly with your assigned probation officer.

Bellevue Probation Services | 1309 114TH Ave SE | Suite 200 Bellevue, WA 98004 | Tel: 425-452-6956 | Fax: 425-452-7883

Case number #

Probation Officer's First and Last Name

Probation Officer's Email

Report is to be filed/sent in by the 5th of each month. This report shall NOT be considered a fulfillment of your reporting condition unless COMPLETED IN FULL.

Contact Information

Name

Email Address

Primary Phone

Address

City

State

ZIP

Other Phone

Employer

Is 'address' new?

Yes

Please check if you are experiencing temporary/permanent houselessness?

Yes

Is 'primary phone' number new?

Yes

Is 'other phone number' new?

Yes

Please fill out all fields below

Have you been arrested, cited, jailed or appeared in court since your last report?

Yes

Details

Date	Location	Charges	Case #
Date	Location	Charges	Case #

Explanation/Disposition:

Are you being supervised in any other office/court?

When placed on probation, you may have been ordered to complete certain conditions.

Attending Substance Use Disorder Treatment

Yes

N/A

In Compliance?

Yes

Taking Antabuse/Methadone/Suboxone/Subutex/Vivitrol/Naltrexone as prescribed

Yes

N/A

Where?

Attending AA

Yes

N/A

Please attach log in PDF format to this report.

Any alcohol or Drug use

Yes

Attending Mental Health Treatment

Yes

N/A

Taking medications as prescribed

Yes

N/A

Attending DV Treatment

Yes

N/A

In Compliance?

Yes

Has there been any victim contact

Yes

N/A

Why?

Fees owed

Court

Probation

Amount last paid to Court

Amount last paid to Probation

Restitution owed

Yes

Amount last paid

Attending school/training program

Yes

Name

Seeking employment

Yes

Where?

Community Service

Yes

Details

Where	Hours this month
Where	Hours this month

Are you driving

Yes

Valid Driver’s License

Yes

State

Do you want to schedule an appointment to see your probation officer

Yes

Comments or questions

Attach AA log pdf

One file only.
10 MB limit.
Allowed types: pdf.

Acknowledgement

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct to the best of my knowledge.

Signature

Full Name	Date
Full Name	Date

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