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PUBLIC SERVICE RESTITUTION PROGRAM Name: DOB: Address: Home Phone: Cell Phone: No.: Offense: Number of hours assigned: To be completed no later than: WORK SCHEDULE: Date Time Total Hours Type of work completed, performance of worker, additional comments: ____Successful completion ____Unsuccessful completion due to Agency Name and phone number: Supervisor's Name and signature: Please return immediately following completion of work or when deadline has expired to: Brenda Dewees, Probation Officer BROWN COUNTY PROBATION DEPARTMENT P.O. BOX 85 NASHVILLE, IN 47448 Phone (812) 988-5505 Fax (812) 988-5506