Eau Claire Police Department Citizen Self-Reporting Form

 

SECTION 1 - MUST BE COMPLETED - ALL BLOCKS ARE REQUIRED
IMPORTANT:

Did you consent to this crime? 

Yes     No

Date(s) Incident Occurred:

   mm/dd/yyyy

 Time(s) Incident Occurred:

    AM  PM
Address Where Incident Occurred.  House Number and Street Name. If not at a specific address, list the block# and street, or nearest intersection.

 

Your Name:   Last, First, MI 

 

Birthdate:

   mm/dd/yyyy
Race:

White               Black                 Asian                Hispanic 

  Pacific Islander           American Indian

 Sex:

Male

Female
Your Address:

 House Number and Street Name/Apt #

  City / State / Zip Code

 

Home Phone #      (xxx) xxx-xxxx            Cell Phone #   (xxx) xxx-xxxx

E-mail Address:  

 

 

SECTION 2  -  BUSINESS / PROPERTY OWNER INFORMATION - COMPLETE IF APPLICABLE
Business Name & Address:

 

Business Phone #

 (xxx) xxx-xxxx
Property Owner's Name:   Last, First, MI 

 

Birthdate:

   mm/dd/yyyy
Race:

White               Black                 Asian                Hispanic 

  Pacific Islander           American Indian

 Sex:

Male

Female
Property Owner's Address:

 House Number and Street Name/Apt #

  City / State / Zip Code

 

Home Phone #      (xxx) xxx-xxxx            Cell Phone #   (xxx) xxx-xxxx
SECTION 3  -  VICTIM VEHICLE       SUSPECT VEHICLE
Vehicle License Plate #

 State:

 Exp:    Mo./Yr.

 Plate Type:

 VIN #

 

 

SECTION 4  -  SUSPECT INFORMATION
Suspect's Name:   Last, First, MI 

 

Birthdate:

   mm/dd/yyyy
Race:

White               Black                 Asian                Hispanic 

  Pacific Islander           American Indian

 Sex:

Male

Female
Suspect's Address:

 House Number and Street Name/Apt #

  City / State / Zip Code

 

Home Phone #      (xxx) xxx-xxxx            Cell Phone #   (xxx) xxx-xxxx

Ht:          

Wt: Build: Hair:  Eyes: Glasses: Facial Hair: Employer:

     

SECTION 5  -  REQUIRED IF PROPERTY WAS STOLEN, OTHERWISE, COMPLETE IF APPLICABLE

STOLEN AND/OR DAMAGED PROPERTY

List all available information
Check appropriate boxes below:         S = Stolen          D = Damaged          L = Lost

S/D/L

Item

Brand

Model/Style

Serial Number

Description

Color

Amount of Loss $
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

 

Insurance Company Information: 

SECTION 6  -  MUST BE COMPLETED
INCIDENT INFORMATION  -  Briefly describe incident making sure to include Location, Date, Time.

By pressing the "submit" button, I (person named in section 1 above) understand that this Citizen Self Report Form will be sent electronically to the Eau Claire Police Department.  I attest that I have read and understand the instructions for completing this police report. (see instructions)  I also attest under penalty of law that information and statements made herein are true and correct to the best of my knowledge.