Form Center

Crime Reporting Form

2. Preliminary Information

3. Date of Complaint*
   Date of Complaint

   Today's Date

5. Type of Crime*
   -- Select One --Identification Theft / FraudGrand Theft (no vehicle or guns)Petty theftCar burglaries (no structures)Harassing phone callsVandalismLost property

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. Best Phone to Reach You*

19. Work Phone

20. Email Address*

22. Date of Birth*
    Date of Birth

23. Age*

24. Gender*
    -- Select One --FemaleMaleUnspecified

28. Victim Information

30. Victim Name (if different)

34. Physical Address

36. Street Address*

38. Street Address 2

40. City*

41. State*

42. Zip Code*

44. Mailing Address if different from Physical Address

46. Street Name and Mailing Address

48. City

49. State

50. Zip Code

54. Crime Details

56. Specific Location*

    Do not list only the town.

58. 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.

60. Description of Crime*

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

62. Description of Property Stolen

64. Was a vehicle involved?

    1. Burglarized
    2. Drive by Suspect

    How was the vehicle involved?

68. If a suspect is located, can you return to the Placer County area for court?*

    1. Yes
    2. No

69. Would you be able to identify a suspect in a photo or physical line-up?*

    1. Yes
    2. No

71. Can you make a positive identification of your missing property?*

    1. Yes
    2. No

72. Is this report for insurance purposes only?*

    1. Yes
    2. No

Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field