Introduction

1) What type of incident are you reporting?

2) Reporting Person Type

Individual - You are reporting this for yourself

Business - You are responsible for reporting this for your employer, government agency, or your own

3) Incident Street Address (Where did the crime occur?)

4) Apartment / Unit (optional)

5) City

6) State

7) ZIP (optional)

8) Incident Date and Time (Start)

9) Incident Date and Time (End)

10) Willing to prosecute

Yes

No

Person/Victim Information

Please enter your information as completely as possible. You may be contacted regarding this incident in order to obtain further information. An email address is required if you would like to be notified when this report is received and approved.

If you are reporting this information for another person please put the victim information on this page and use the additional person section to submit your information as the Reporting Party.

11) Victim / Business Victim

Victim

Business Victim

12) First Name

13) Middle Name (optional)

14) Last Name

15) Suffix (optional)

16) Address (optional)

17) Apartment / Unit (optional)

18) City (optional)

19) State

20) ZIP

21) Home Phone (optional)

22) Mobile Phone (optional)

23) Email

24) Race

25) Ethnicity

Hispanic

Not Hispanic

Unknown

26) If Native American what tribe are you affiliated with? (optional)

i.e. Cherokee, Creek, etc.

27) Sex

Male

Female

28) Hair Color (optional)

29) Eye Color (optional)

30) Drivers License Number

31) Date of Birth

Enter date of birth in format xx/xx/xxxx

32) License Class (optional)

33) Licensing State

34) Height (Feet) (optional)

35) Weight (optional)

36) Spoken Language

Additional Person Information

If you have additional people to add to the report, please do so here:

If no additional person is required skip to question 71 optional vehicle information. If no vehicle information is needed skip to question 83 property section. If you don't need to enter any of these skip to question 84 narrative section.

37) Additional Person 1: Involvement Type (optional)

Suspect - If you know who committed this crime, enter as much info as you know

Victim - If there are more than one victims to this crime

Person Reporting - If you are reporting this crime for another individual

Witness - If someone witnessed this crime

38) Additional Person 1: First Name (optional)

39) Additional Person 1: Last Name (optional)

40) Additional Person 1: Age (optional)

41) Additional Person 1: Suffix (optional)

42) Additional Person 1: Home Address (optional)

43) Additional Person 1: Apartment / Unit (optional)

44) Additional Person 1: City (optional)

45) Additional Person 1: State (optional)

46) Additional Person 1: Zip (optional)

47) Additional Person 1: Home Phone (optional)

48) Additional Person 1: Mobile Phone (optional)

49) Additional Person 1: Email (optional)

50) Additional Person 1: Employer Name (optional)

51) Additional Person 1: Work Address (optional)

52) Additional Person 1: Work Phone (optional)

53) Additional Person 1: Race (optional)

54) Additional Person 1: Ethnicity (optional)

Hispanic

Not Hispanic

Unknown

55) Additional person: Tribe affiliation (optional)

If the additional person is Native American what tribe are they affiliated with?

56) Additional Person 1: Resident Status (optional)

Nonresident

Resident

Unknown

57) Additional Person 1: Sex (optional)

Male

Female

58) Additional Person 1: Eye Color (optional)

59) Additional Person 1: Hair Color (optional)

60) Additional Person 1: Driver's License Number (optional)

61) Additional Person Date of Birth (optional)

Format xx/xx/xxxx

62) Additional Person 1: Licensing State (optional)

63) Additional Person 1: License Class (optional)

64) Additional Person 1: Height (optional)

65) Additional Person 1: Weight (Pounds) (optional)

66) Additional Person 1: Spoken Language (optional)

67) Additional Person 2 (optional)

Enter any of the above relevant information here for additional person 2, if any

68) Additional Person 3 (optional)

Enter any of the above relevant information here for additional person 3, if any

69) Additional Person 4 (optional)

Enter any of the above relevant information here for additional person 4, if any

70) Additional Person 5 or more (optional)

Enter any of the above relevant information here for additional persons 5 or more, if any

Optional: Vehicle Information

If relevant to the incident you are reporting, please enter vehicle details.

71) Make: (optional)

ex: Nissa, Acura, Alfa Romeo, etc.

72) Model: (optional)

73) Vehicle Type (optional)

74) Vehicle Year (optional)

75) Vehicle Identification Number (VIN) (optional)

76) Vehicle Color (optional)

77) License Plate Number (optional)

78) License State (optional)

79) Insurance Company (optional)

80) Insurance Policy Number (optional)

81) Insurance Phone Number (optional)

82) Damaged Area On Vehicle (optional)

83) Property Section (optional)

Please describe if item was stolen or vandalized. List any items that were stolen or vandalized when include item type, quantity, brand and model, serial number, and value.

84) Narrative Section:

Please type a description of what occurred basically the who, what, when, and where of what happened.

85) Incident image(s) / Documents (optional)

Max 10 files | 200 MB limit

Forms