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2. Today's Date*
   Today's Date
3. Citation or Case #
4. Date & Time of Occurrence*
   Date & Time of Occurrence

   Date & Time of Occurrence
6. Name*
7. Address*
9. Phone Number*
10. Email Address*
12. Name(s) and Badge Number(s) of Officer(s) Involved (If Known)
14. Witnesses' Names, Addresses, and Phone Numbers (If Known)
16. Statement of Facts*
18. Electronic Signature*

    1. By checking this box, I certify that all of the information is true and accurate to the best of my knowledge.
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20. 1. Receive an email copy of this form.
21. Email address

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