SAMPLE								SAMPLE
THORNTON MUNICIPAL COURT
COMMUNITY SERVICE WORK LOG

THE COMMUNITY SERVICE WORKER (NOT THE JOB SITE) SHALL RETURN THIS FORM TO THE COURT BY THE DEADLINE GIVEN.

Name/Summons Number:___Your Name/_6000000______

Work Site Name:____Helping Hands-Non-Profit Organization___

Work Site Address:____123 Main St., Anywhere, USA___________

Signature of person for whom the work was done:____Jane Smith____

Printed Name of person for whom work was done:____Jane Smith_____

Contact Phone Number for Job Site:____303-555-1212_____________

How does this site qualify for Community Service?  Check one:
[ X ] Non-Profit Organization   [  ] Elderly (non-relative)   [  ] Disabled (Non-relative)
•	You can do an internet search for “non-profit near me” for suggested locations. 

NOTE: Community service hours for a non-related elderly or disabled individual is authorized for a JUVENILE ONLY given their age may limit access to non-profit organizations.  An adult would need to get Court approval prior to community service hours being completed for an elderly or disabled individual.

WORK LOG – TO BE DOCUMENTED DAILY
Date			Nature of Work Performed	Hours Worked
01/01/16		Sorting Clothes			8:00-5:00= 8 hrs. 
01/03/16		Sweeping Floors			8:00-10:00= 2 hrs. 
01/04/16		Filing					8:00-2:00= 6 hrs. 
01/07/16		Assisting Shoppers	   	10:30-3:30= 5hrs.
________________________________________________________
			TOTAL HOURS WORKED:	21 hrs TOTAL    

By signing below, I swear and affirm the above information is true and accurate to
the best of my ability, and that if I provide false information, I could be subject to contempt proceedings.

___Defendant’s Signature________________________			__Today’s Date__
Defendant’s Signature							Date

THORNTON MUNICIPAL COURT
COMMUNITY SERVICE WORK LOG

THE COMMUNITY SERVICE WORKER (NOT THE JOB SITE) SHALL RETURN THIS FORM TO THE COURT BY THE DEADLINE GIVEN.

[ X ]	COMMUNITY SERVICE HOURS ORDERED: ______________
Proof of completion must be provided by your scheduled court hearing date OR YOU MUST APPEAR BEFORE THE COLLECTIONS OFFICER at your scheduled court date and time.	
		
Defendant’s Name:									

Summons Number:									

Work Site Name:_________________________________________ __________

Work Site Address:_______________________________ __________________

Signature of person for whom the work was done:____________ _____________

Printed Name of person for whom work was done:____________ _____________

Contact Phone Number for Job Site:_______________ _____________________

How does this site qualify for Community Service?    Check one:
[  ] Non-profit Organization    [  ] Elderly (non-relative)    [  ] Disabled (non-relative)
•	You can do an internet search for “non-profit near me” for suggested locations. 

NOTE: Community service hours for a non-related elderly or disabled individual is authorized for a JUVENILE ONLY given their age may limit access to non-profit organizations.  An adult would need to get Court approval prior to community service hours being completed for an elderly or disabled individual.

WORK LOG- TO BE DOCUMENTED DAILY
Date worked	  Nature of Work Task Performed	  Hours worked 

					

					

					TOTAL HOURS WORKED:   ___________

By signing below, I swear and affirm the above information is true and accurate to
the best of my ability, and that if I provide false information, I could be subject to contempt proceedings.

__________________________________________			_______________
Defendant’s Signature							Date