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Run: Court-Ordered Community Service Hours Verification Form

Track court-ordered community service from order details to supervisor sign-off in one verification form. Use it to document hours, confirm conduct, and prod...

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Court Order Information

Court Case Number (required)

Enter the case number exactly as it appears on your court order or diversion agreement.

Issuing Court Name (required)

Date of Court Order or Diversion Agreement (required)

The date the judge signed the order or the diversion agreement was executed.

Court-Mandated Completion Deadline (required)

The date by which all hours must be completed per the court order.

Type of Obligation (required)

If 'Other', please describe the obligation type

Total Community Service Hours Ordered by Court (required)

Enter the exact number of hours specified in the court order.

Participant Information

Participant Full Legal Name (required)

Date of Birth (required)

Required for identity verification and court record matching only.

Government-Issued ID Type Presented (required)

Last 4 Digits of ID Number (required)

Only the last 4 digits are collected to protect PII while enabling record verification.

Participant Phone Number (required)

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 (required)

Agency Street Address (required)

Agency Phone Number (required)

Type of Community Service Performed (required)

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 (required)

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) (required)

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 (required)

Enter 0 if the obligation is fully satisfied.

Current Obligation Status (required)

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 (required)

Supervisor Title / Role (required)

Supervisor Direct Phone Number (required)

Supervisor Email Address (required)

A copy of this verification will be sent to this address for agency records.

Participant Conduct and Reliability (required)

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 (required)

Check this box only if you have cross-referenced the session log with your agency's own attendance records.

Yes No N/A

Supervising Officer Signature (required)

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 (required)

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. (required)

Yes No N/A

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. (required)

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.

Yes No N/A

Participant Signature (required)

Sign to confirm your attestation above.

Date Signed (required)

Additional Notes or Special Circumstances

Optional. Use this field to document any court-approved exceptions or circumstances relevant to this submission.

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