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Eau Claire County
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    721 Oxford Ave Eau Claire, WI 54703
Home > Public Safety > Sheriff > Forms > Self Reporting Form
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Self Reporting Form
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 Citizen's 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 under penalty of law that information and statements made herein are true and correct to the best of my knowledge.

 

 

 

 

 

 

 

 

 

 

 

 



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