Fifth Judicial District - Department of Correctional Services

Monthly Report

[ To be received by the 10th of each month ]

** NOTE: If you are being supervised in Polk county and your officer is not listed in the form below you may not have to fill out monthly reports any longer. Please see the offender information screen for instructions and to view the new packet information.

** You must select an Officer from the list below before submitting the report. If your officer's name is not in the list please contact them to determine how you are supposed to proceed.

  • * Select Officer:
  • ICON Number:
  • * Name:
  • Home Phone: (ex. 555-555-5555)
  • Cell Phone: (ex. 555-555-5555)
  • Email Address:
  • Has your address changed?      YES NO
  • If yes, date of change?      
  • * Address:
  • * City:
  • * State:
  • * Zipcode:



  • Has your employer changed? YES NO
  • If yes, date of change?
  • * Employer:
  • * Employer Address:
  • * Employer Phone: (ex. 555-555-5555 12345)


  • Financial obligations due (fines/court costs, etc.):
  • Balance of Community Service hours:     Where:  
  • VORP (when applicable) When:
  • Other (i.e.) When applicable:
  • OWI weekend programs, 1st or 2nd offense:    provide certificate
  • Substance abuse evaluatioin:    provide certificate
  • Treatment Referrals (Where):    provide certificate
  • Classes Attended (When):    provide certificate
  • Completed Jail Sentence (When):    provide certificate


  • Have you been arrested, questioned, or given a ticket since last report? YES NO
  • If yes, briefly describe circumstance:
  • Comments:
  •  
  • * Client signature:               * Date:  


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