Citizen Self-Report Form

INSTRUCTIONS: This is a law enforcement document that will become the official police report for this incident. If you do not complete the required fields and click submit, there will be no official police report on file. Please note that YOU MUST INCLUDE YOUR FULL NAME AND DATE OF BIRTH for the report to be officially filed.

We will be able to follow-up on your case if you provide us with as much information as possible. These directions are provided to assist you in completing the form below.

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The following information is regarding YOU (the person completing this report)

1

Your Contact Information (mandatory):

 *

Your Contact Information (mandatory):

First Name:

Middle Initial:

Last Name:

Your Date of Birth:

2

Gender (mandatory):

 *

Gender (mandatory):(Select an Answer) Male Female

3

I am filing this report as (mandatory):

 *

I am filing this report as (mandatory):

A Victim

A Reporting Person

A Property Owner

4

Your Address (mandatory):

 *

Your Address (mandatory):

Street Address:

City:

State:

Zip Code:

Phone Number:ext.

Email Address:

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Please complete as much of this form as possible before submitting. By submitting this form, you certify under penalty of law that all the information supplied in this report is true and correct to the best of your knowledge.

5

Incident Report Type (mandatory - select most appropriate):

 *

Incident Report Type (mandatory - select most appropriate):

Theft

Vehicle Break-In

Vandalism

Damage to Property

Lost/Missing Property

6

Date and Time Last Known Prior to Criminal Activity (mandatory):

 *

Date and Time Last Known Prior to Criminal Activity (mandatory):

Date:

Approximate Time (include AM/PM):

7

Date and Time Criminal Activity was Discovered (mandatory):

 *

Date and Time Criminal Activity was Discovered (mandatory):

Date:

Approximate Time (include AM/PM):

8

Location Type Where Criminal Activity Occurred:

 *

Location Type Where Criminal Activity Occurred:

Residence

Business

School

Parking Lot

Other If other, type text here.

9

Business/Property Owner (if different than above):

Business/Property Owner (if different than above):

First Name:

Middle Initial:

Last Name:

Date of Birth:

10

Gender:

Gender:(Select an Answer) Male Female

11

Address Where Criminal Activity Occurred (mandatory - must be within City of Appleton):

 *

Address Where Criminal Activity Occurred (mandatory - must be within City of Appleton):

Street Address:

City:

State:

Zip Code:

12

Briefly Describe the Incident that Occurred (mandatory - be concise):

 *

Briefly Describe the Incident that Occurred (mandatory - be concise):

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The next section is broken-up into three segments: property information, bicycle information, and vehicle information. Please complete the one section that is most appropriate for your situation.

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Property Information

13

Property Status (if applicable):

Property Status (if applicable):

Damaged

Stolen

Lost/Missing Property

14

Property Details (if applicable):

Property Details (if applicable):

Type of Property:

Brand Name:

Serial Number:

Estimated Value ($):

Additional Description:

Insurance Company:

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Bicycle Information

15

Bicycle Status (if applicable):

Bicycle Status (if applicable):

Damaged

Stolen

Lost/Missing Property

16

Bicycle Information (if applicable):

Bicycle Information (if applicable):

Brand Name:

Model:

Year:

Color:

Wheel Size:

Speed:

Serial Number:

Additional Description:

Estimated Value ($):

Insurance Company:

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Vehicle Information

17

Vehicle Information (if applicable):

Vehicle Information (if applicable):

License Plate:

State of Plate:

Vehicle Type:

Color:

Year:

Make:

Model:

Body Style:

VIN:

Estimated Damage ($):

Insurance Company:

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18

Providing FALSE INFORMATION, Pursuant to State Statute 946.41(2m)(a), is a FELONY.

 I, the complainant and/or reporting person, did not give anyone permission to commit this crime against my person or property (mandatory).

 *

Providing FALSE INFORMATION, Pursuant to State Statute 946.41(2m)(a), is a FELONY. I, the complainant and/or reporting person, did not give anyone permission to commit this crime against my person or property (mandatory).

True

False

19

Electronic Signature (mandatory):

 *

Electronic Signature (mandatory):

Full Name:

Date:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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