Citizens' Self Reporting

Print

If you would like to report an incident online, fill out the information below and click Submit.  

OR

Complete this printable form

and email to Mike.Mayer@co.eau-claire.wi.us
OR Print and mail/fax to Sheriff Department Records Division at address below    

Eau Claire County Sheriff’s Office
Administrative Services/Records Division
721 Oxford Avenue, Suite 1400
Eau Claire, WI 54703
Fax Number: (715) 839-4854

Please correct the field(s) marked in red below:

SECTION 1 - MUST BE COMPLETED - ALL BLOCKS REQUIRED

IMPORTANT: Did you consent to this crime?

 *
IMPORTANT: Did you consent to this crime?

Date(s) Incident Occurred: (mm/dd/yyyy)

 *

Time Incident Occurred: 

 *
Address Where Incident Occurred.  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:

 *
Race:

Sex:

 *
Sex:

Your Address: House / Apt Number, Street Name, City, State, Zip

 *

Home Phone: (xxx-xxx-xxxx)

 *

Cell Phone: (xxx-xxx-xxxx)

 *

Email Address:

 *
SECTION 2 - BUSINESS / PROPERTY OWNER INFORMATION - COMPLETE IF APPLICABLE  

Business Name and Address:

Business Phone: (xxx-xxx-xxxx)

Property Owner's Name: Last, First, MI

Birthdate: (mm/dd/yyyy)

Race:

Race:

Sex:

Sex:

Property Owner's Address: House/Apt #, Street Name, City, State, Zip

Home Phone: (xxx-xxx-xxxx)

Cell Phone: (xxx-xxx-xxxx)

SECTION 3 - VEHICLE INFORMATION

Victim or Suspect Vehicle?

Victim or Suspect Vehicle?

License Plate #:

State:

Expiration Month/Year:

Plate Type:

VIN#:

SECTION 4 - SUSPECT INFORMATION

Suspect Name: Last, First, MI

Birthdate: (mm/dd/yyyy)

Race:

Race:

Sex:

Sex:

Suspect's Address: House/Apt #, Street Name, City, State, Zip

Home Phone: (xxx-xxx-xxxx)

Cell Phone: (xxx-xxx-xxxx)

Height:

Weight:

Build:

Build:

Hair:

Hair:

Eyes:

Eyes:

Glasses:

Glasses:

Employer:

SECTION 5 - REQUIRED IF PROPERTY WAS STOLEN, OTHERWISE, COMPLETE IF APPLICABLE
STOLEN AND/OR DAMAGED PROPERTY

Item 1:
Check appropriate box
S=Stolen    D=Damaged    L=Lost

Item 1: Check appropriate box S=Stolen D=Damaged L=Lost

Item 1: (bike, cellphone, etc)

Item 1 Make/Brand: 

Item 1 Model/Style:

Item 1 Serial #:

Item 1 Description:

Item 1 Color:

Item 1 Amount of Loss:

Item 2:
Check appropriate box
S=Stolen    D=Damaged    L=Lost

Item 2: Check appropriate box S=Stolen D=Damaged L=Lost

Item 2: (bike, cellphone, etc)

Item 2 Make/Brand: 

Item 2 Model/Style:

Item 2 Serial #:

Item 2 Description:

Item 2 Color:

Item 2 Amount of Loss:

Item 3:
Check appropriate box
S=Stolen    D=Damaged    L=Lost

Item 3: Check appropriate box S=Stolen D=Damaged L=Lost

Item 3: (bike, cellphone, etc)

Item 3 Make/Brand: 

Item 3 Model/Style:

Item 3 Serial #:

Item 3 Description:

Item 3 Color:

Item 3 Amount of Loss:

Item 4:
Check appropriate box
S=Stolen    D=Damaged    L=Lost

Item 4: Check appropriate box S=Stolen D=Damaged L=Lost

Item 4: (bike, cellphone, etc)

Item 4 Make/Brand: 

Item 4 Model/Style:

Item 4 Serial #:

Item 4 Description:

Item 4 Color:

Item 4 Amount of Loss:

Item 5:
Check appropriate box
S=Stolen    D=Damaged    L=Lost

Item 5: Check appropriate box S=Stolen D=Damaged L=Lost

Item 5: (bike, cellphone, etc)

Item 5 Make/Brand: 

Item 5 Model/Style:

Item 5 Serial #:

Item 5 Description:

Item 5 Color:

Item 5 Amount of Loss:

Insurance Company Information:

SECTION 6 - MUST BE COMPLETED

INCIDENT INFORMATION: Briefly describe incident making sure to include location, date, time.

 *
  1. To receive a copy of your submission, please fill out your email address below and submit.