Steuben County Probation Department

Steuben County Probation Department

Provisional/ Temporary Travel Permit

Adult form IX

__ Provisional __ Temporary Date:__/__/__

Full Name: ______Alias(es):______

Indiana Cause #:______Other Case #:______

DOB: __/__/__ Sex:___ Race:___ Hair:___ Eyes:___ Ht:___ Wt:___

************************************************************************Destination:______

(address) (city)

______Telephone:______

(state) (zip)

Purpose of Trip:______

Date of Departure:__/__/__ Date of Return:__/__/__

Means of Travel:______

(give description of vehicle; flight, train, bus info., etc.)

Accompanied By:______Relationship:______

************************************************************************Offense(s): ______

Length of Probation: ______Felony __Misdemeanor

Any History of Crimes Against Persons? __Yes __No

************************************************************************Waiver of Extradition

I have been given this permission to travel outside the Court’s Jurisdiction with the explicit understanding that I am to continue faithfully to follow the rules of my probation and to travel only to the location specified above. If I should be arrested in any other State during the period of travel granted me, I will waive extradition proceedings and will voluntarily return to Indiana.

Signed: Approved By:

______

(probationer) Judge, Steuben County Indiana

Date Signed:__/__/__

I agree to report back or call

My Probation Officer by: __/__/__