Eau Claire County

Wisconsin
Eau Claire County

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721 Oxford Ave Eau Claire, WI 54703
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Citizens Reporting Form

Community and Education Programs

Eau Claire County Sheriff's Office
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 Occured:
(mm/dd/yyyy) Time(s) Incident Occured:

Address Where Incident Occured. House Number and Street Name. If not 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 # 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/yy

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 # 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 #
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
(ie, bike,
cellphone) Make/Brand Model/Style Serial # 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 County Sheriff's office. 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.

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