+------------------------+----------------------+----------------------+
| **United States        |                      |                      |
| District Court**       |                      |                      |
|                        |                      |                      |
| DISTRICT OF NEBRASKA   |                      |                      |
|                        |                      |                      |
| ![](media/image1.emf)  |                      |                      |
| PROBATION OFFICE       |                      |                      |
+------------------------+----------------------+----------------------+
| **JAMES P. ROWOLDT**   |                      | 111 SOUTH 18^th^     |
|                        |                      | PLAZA, SUITE C79     |
| **CHIEF PROBATION      |                      |                      |
| OFFICER**              |                      | OMAHA, NE 68102-1312 |
|                        |                      |                      |
| **YADOR J. HARRELL**   |                      | COMM (402) 661-7555  |
|                        |                      |                      |
| **DEPUTY CHIEF         |                      | FAX (402) 661-7550   |
| PROBATION OFFICER**    |                      |                      |
+------------------------+----------------------+----------------------+

According to the conditions of your sentence, you are responsible for
completing hours of community service. This form is to provide
verification information of those hours.

Name of
agency\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  ---------- ------------- -------------------------- ----------------------
  **Date**   **Number of   **Type of Work Completed** **Signature of
             Hours                                    Supervisor**
             Worked**                                 

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      

                                                      
  ---------- ------------- -------------------------- ----------------------

I affirm that the information provided on this form is true and correct.

Signed:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Additional space is provided on the back of this form. You are required
to bring this form each time you visit your Probation Officer. Should
you have any questions, please do not hesitate to contact your officer.

  ---------- ------------- ------------------------- ---------------------
  **Date**   **Number of   **Type of Work            **Signature of
             Hours         Completed**               Supervisor**
             Worked**                                

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     

                                                     
  ---------- ------------- ------------------------- ---------------------