Complaint Report

Victim Information / Complaint Form

Today's Date

Current Time

A.M.

P.M.

Date of Offense

Time of Offense

A.M.

P.M.

Address of Offense

City of Offense

State

Zip

Type of Victim

Race

Sex

Victim Status

Total No. of Victims

Was Victim Injured

Describe Victims Injuries

Last Name of Victim

Home Phone No.

First Name of Victim

Work Phone No.

Victims Middle Initial

Victims Home Address

City

State

Zip

Date of Birth

Height

Weight

Hair

Eyes

Occupation

Employers Name

Employers Address

City

State

Zip

In the box below please describe the event in which you are reporting. Please be as truthful , accurate and complete as possible. Please remember to use full names instead of nicknames and correct addresses when possible this box will expand while you type to insure you have plenty of space to describe places, events and witnesses.