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2. Preliminary Information
3. Date of Complaint*
   Date of Complaint
   Today's Date
5. Type of Crime*
   -- Select One --Identification Theft / Fraud (Someone is using your personal info for financial gain)Grand Theft (no vehicle or guns and over $950)Petty theft (Less than $950 loss)Car burglaries (no structures)Harassing phone callsVandalism (Graffiti, damage to vehicle, etc)Lost propertyIllegal DumpingMail Theft (From your mailbox)
7. If your crime is not listed, please refer to:
   Placer County Dispatch
11. Your Information
13. First Name*
14. Middle Name
16. Last Name*
17. Phone*
19. Email Address*
21. Date of Birth*
    Date of Birth
22. Age*
23. Gender*
    -- Select One --FemaleMaleUnspecified
27. Victim Information
29. Victim Name*
30. Phone*
32. Victim Physical Address
34. Street Address*
36. Street Address 2
38. City*
39. State*
40. Zip Code*
42. Mailing Address if different from Physical Address
44. Street Name and Mailing Address
46. City
47. State
48. Zip Code
52. Crime Details
54. Specific Location of Crime (Street Address or Cross Street, etc)*

    Do not list only the town.

56. City*
57. State*
58. Zip Code*
60. Crime Occurred Between*
    Crime Occurred Between Start Date

    Crime Occurred Between Start Time

    —

    Crime Occurred Between End Date

    Crime Occurred Between End Time
    Approximate times are acceptable.
62. Description of Crime*

    Please describe what happened in chronological order being as detailed as possible.

64. Description of Property Stolen

    In order to expedite your case, please provide the approximate total value and serial numbers for each item stolen along with the description.

66. Value/Damage of Stolen Items (If not applicable enter $0.00)*
68. Was a vehicle Involved?

    Please describe the license plate, make, model, style and any other pertinent details of the vehicle.  

72. Is this report for insurance purposes only?*

    1. Yes
    2. No
Leave This Blank:


74. Submit

* indicates a required field