Please type in your real name: Please input your email address: Street Address: City, State and Zip: PLEASE FILL OUT BOTH BOXES BELOW WITH A DESCRIPTION OF WHAT HAPPENED
Please describe the incident in full, including the time, date, place, any license numbers or badge numbers, make and color of vehicle, what all parties did immediately prior, during, and after the incident, etc. If someone was cited or arrested, please tell what the charge(s) were and what became of them. Were there injuries? If so, what happened with the injuries? Please be as clear and complete as possible and describe the incident in as chronological a manner as possible. The lines provided are just a guideline to remind you to be as complete as possible. DESCRIPTION OF INCIDENT: Were you the victim? Were you a witness? Date of incident: Day of the week: Time of day: AM or PM? Weather conditions: Raining? Dark, dusk/dawn, or light out? Location(s) of incident: Street address: City: Country: Individuals involved: Witness names: Officer names: Officer badge numbers: Was anyone arrested or ticketed? Who? Were they taken into custody? What was the charge? Infraction, Misdemeaner, or Felony? Identity of aggressor/attacker/perpetrator of abuse: License plate number(s): Badge number(s): Was anyone injured? Who? Hospitalized? What were their injuries? How did their injuries occur? FULL DESCRIPTION OF WHAT HAPPENED IN YOUR OWN WORDS: What happened next? Did you file a complaint? File a lawsuit? PLEASE DESCRIBE WHAT HAPPENED FOLLOWING THE INCIDENT: Complaint filed? With whom? Against whom? What was the result? Did any injuries heal? How long until they healed? Were there permanent injuries or fatality? Was there legal action on behalf of the victim? What was the result? FULL DESCRIPTION OF WHAT HAPPENED AFTER THE INCIDENT IN YOUR OWN WORDS:
We respect your privacy. Please check one of the following boxes. Note that there may be some situations in which we may be ordered to hand over this information by the legal system.
