Court-Ordered Community Service Hours Verification Form

Captures court order details, supervising officer information, scheduled service hours, and certified completion of community service obligations. Used by host agencies to document and verify that individuals are fulfilling diversion or sentencing requirements.

Court Order Information

• Court Case Number
  Enter the case number exactly as it appears on your court order or diversion agreement.
• Issuing Court Name
• Date of Court Order or Diversion Agreement
  The date the judge signed the order or the diversion agreement was executed.
• Court-Mandated Completion Deadline
  The date by which all hours must be completed per the court order.
• Type of Obligation
• If 'Other', please describe the obligation type
• Total Community Service Hours Ordered by Court
  Enter the exact number of hours specified in the court order.

Participant Information

• Participant Full Legal Name
• Date of Birth
  Required for identity verification and court record matching only.
• Government-Issued ID Type Presented
• Last 4 Digits of ID Number
  Only the last 4 digits are collected to protect PII while enabling record verification.
• Participant Phone Number
  Used only to contact the participant regarding scheduling or documentation issues.
• Participant Email Address
• Assigned Probation / Diversion Officer Name
• Probation / Diversion Officer Phone or Email

Host Agency and Service Site

• Host Agency / Organization Name
• Agency Street Address
• Agency Phone Number
• Type of Community Service Performed
  Select all categories that apply to the work performed at this site.
• Specific Work Location or Site Notes

Scheduled and Completed Service Hours

• Service Session Log
  Add one row per service shift. Date, start time, end time, and supervisor initials are required for each session.
• Total Hours Completed (as reported above)
  Sum all hours from the session log above and enter the total here. This figure will be verified by the supervising officer.
• Hours Still Remaining to Fulfill Court Order
  Enter 0 if the obligation is fully satisfied.
• Current Obligation Status
• Attach Supporting Timesheets or Sign-In Logs (if required)
  Upload scanned timesheets, sign-in sheets, or other documentation. Accepted formats: PDF, JPG, PNG. Max 10 MB per file.

Supervising Officer Verification

• Supervising Officer Full Name
• Supervisor Title / Role
• Supervisor Direct Phone Number
• Supervisor Email Address
  A copy of this verification will be sent to this address for agency records.
• Participant Conduct and Reliability
  Supervisor's assessment of the participant's behavior and attendance during service.
• Supervisor Comments on Conduct or Performance
  Required if conduct was rated Marginal or Unsatisfactory.
• I have independently verified the hours recorded in the session log against agency sign-in records
  Check this box only if you have cross-referenced the session log with your agency's own attendance records.
• Supervising Officer Signature
  By signing, the supervising officer certifies that the information provided is accurate and complete to the best of their knowledge, and that the participant performed the described service under their oversight.
• Date Signed

Participant Attestation and Consent

• I certify that all information I have provided on this form is true, accurate, and complete. I understand that falsifying community service records may constitute contempt of court or a separate criminal offense.
• I consent to this form and the information it contains being shared with the issuing court, my assigned probation or diversion officer, and any other parties legally required to receive it for the purpose of verifying my compliance with the court order.
  Your information will be used solely for court compliance verification and will be retained in accordance with applicable records retention laws. You have the right to request a copy of this record.
• Participant Signature
  Sign to confirm your attestation above.
• Date Signed
• Additional Notes or Special Circumstances
  Optional. Use this field to document any court-approved exceptions or circumstances relevant to this submission.