Fill and Sign the As Promulgated by the State Intervention Mississippi Supreme Court Form

201 9 AOC Juvenile Officer State Reimbursement Form Turn Over to Complete 1 | P a g e Ju dicial District: County : Instructions: When you have turnover in a juvenile officer position, please include all the officers who were in that position in 201 9. Include the juvenile officer’s name and indicate if the officer is intake by (I) or probation (P) . For example, Sam Jones (I). If your county has a contract for your intake and probation services, please indicate by an (*) by the name . For example, * Sam Jones (I). A copy of the contract must also be submitted for reimbursement for the salary year seeking reimbursement. Provide the hire date and the months in 201 9 the officer was in th is position. Indicate the year the Juvenile Officer received the ir original AOC Juvenile Officer Certification Training and the number of continuing education hours they received approved by the Circuit Court Juvenile Judge in 20 19 . Provide AOC Juvenile Officer Continuing Education form signed by judge , if not already provided. If another county is claiming reimbursement for a juvenile officer listed on this form, indicate what county and what is the percentage (not to exceed 100%) that the officer works in each county to determine the reimbursement for multiple count ies. For example, top of form is for county A, but an officer also works in County B . You would include B/ 15% and A/ 85% to indicat e the reimbursement split. If this does not apply, please put N/A. Please indicate the gross salary paid by the county bas ed on the attached W2s that are required to be submitted with the reimbursement form. Juvenile Officer Position Juvenile Officer Name & Intake (I) / Probation Contractor (*) Hire Date 201 9 Dates by Month in this position Certification Year & 201 9 Continuing Education Hours Other County/ Percentage 201 9 Salary Paid by County (Line 3 on W 2) Position 1 Position 2 Position 3 Position 4 Position 5 Position 6 Position 7 Position 8 Position 9 Position 10 201 9 AOC Juvenile Officer State Reimbursement Form Turn Over to Complete 2 | P a g e I hereby certify that the above information is correct and that juvenile officers have been employed by __________ County in 201 9. Circuit or County Judge: _____________________________ Signature Print Name : _____________________________ Please forward form s, W2s , and contracts, if applicable, to Kenya Washington by email at Kenya.Washington@arcourts.gov fax (501) 682 -2662 or mail to AOC, Justice Building 625 Marshall, LR AR, 72201 by June 1, 20 20 . PLEASE INDICATE TO WHOM AND WHERE TO MAIL STATE REIMBURSEM ENT BELOW: