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2. CAD File #
4. Today's Date Is?*
   Today's Date Is?

   Today's Date Is?
6. The Crime/Incident Happened On or Between?*
   The Crime/Incident Happened On or Between? Start Date

   The Crime/Incident Happened On or Between? Start Time

   —

   The Crime/Incident Happened On or Between? End Date

   The Crime/Incident Happened On or Between? End Time
8. Name*
9. Email Address
11. Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Where Do You Work?*
20. What Is Your Birthdate?*
22. Where Did This Crime/Incident Take Place? *
24. Please Write Down What Happened:*
    If you need extra space use next two blocks...
26. Narrative Cont.
28. Narrative Cont.
30. Did Anyone See This Happen?*

    1. Yes

    1. No
32. If YES, Then Who Are The Witnesses And How May They Be Contacted?
34. Do You Know Who Did This? Any Suspects?*

    1. Yes

    1. No
36. If YES, Who Are The Suspects or Persons Who Did This?
38. If you Don't Know Who Did This, Can You Describe Them?*

    1. Yes

    1. No
40. Describe The Suspect(s):
42. What Were The Suspect(s) Wearing?*
44. What Were The Suspect(s) Driving?*
46. Make:
47. Model:
48. Style:
50. Color:
51. License Plate #
52. VIN:
54. Did Someone Damage or Take Something From Your Vehicle?*

    1. Yes

    1. No
56. Item That Was Taken:
57. Brand/Color/Style:
58. Serial Number:
60. Cost:
61. Other Details:
63. If You Have Other Items Missing, Describe Here Using The Same Format As Above:
65. If Your Vehicle Was Damaged, Describe The Damage:
67. Describe Your Vehicle
69. Make:
70. Model:
71. Style:
73. Color:
74. License Plate #
75. VIN:
77. I swear and affirm that the information I have put forth is true and correct. I understand that filing a police report that contains false accusations is a crime and that I may be prosecuted for giving information I know to be untruthful. I understand by submitting this form electronically or otherwise that I am filing an official police report subject to the prosecution guidelines described above.
79. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
81. Electronic Signature*
83. This report has been reviewed by _________________________ on ____________________. I have identified the offense herein
85. as the offense or incident of _____________________________________________.
87. Reviewing Officer's Signature: ______________________________________
Leave This Blank:


89. 1. Receive an email copy of this form.
90. Email address

    This field is not part of the form submission.

91. Submit

* indicates a required field