Citizen Crime Report (PDF)

 

 

Use of this form is limited to reports of minor theft (under $1000) and criminal mischief (under $1000) without a known suspect or evidence and you were not injured.

Reading Police Department Citizen Crime Report

 

 

OCA/Case #:   -                       (Official use only)     CT   UCR CODE:                                

RECORDS USE ONLY

 

Today’s Date:         /_      _/         Current Time:                 ☐ AM      ☐ PM

 

 

PLEASE PRINT Your Information:
Last Name: __________________________ First name: _______________________ Middle Initial: _________
Street Address: ___________________________________________________________ Apt: ___________
City: _____________________________________ State: __________ Zip: ____________ - __________
Phone #: Home (___) _____ -_____ Work (___) _____ -_____ Mobile (___)____-_____ Other (___)___-____
E-mail Address: __________________________________________________________________________
Sex: ☐Male  ☐Female    Race: ___________ Ethnicity: _________(Hispanic or Non-Hispanic)
Victim’s Age_______ Date of Birth ___/___/______ Occupation ___________________________________

 

Name of Business (if applicable): ____________________________________________________________
Street Address: __________________________________________________________ Apt. ____________
City: _______________________________________ State: ___________ Zip: ___________ - _________

 

Location Where Crime Occurred:    Residence:☐    Business:☐    School:☐    Other ____________________
Address: ______________________________________________________________________________
Date Crime Occurred: _____/_____/______ Time Crime Occurred: _________ ☐ AM ☐ PM
OR
Date/Time Period Crime Occurred: Between _____/_____/_______ __________ ☐ AM ☐PM
and _____/____/_______ _________ ☐ AM ☐ PM

 

Status/Condition of Property: (List value of loss or damage estimate below)
DESCRIPTION: _______________________________________________________ ☐Stolen  ☐Damaged
Value: $_____________ Make______________ Model____________ Serial Number ____________________
DESCRIPTION: _______________________________________________________ ☐Stolen  ☐Damaged
Value: $_____________ Make______________ Model____________ Serial Number ____________________
DESCRIPTION: _______________________________________________________ ☐Stolen  ☐Damaged
Value: $_____________ Make______________ Model____________ Serial Number ____________________
Additional property loss can be placed in the narrative portion on page #2 of this report.

WITNESSING OFFICER:

COMPUTER #:

REVIEWING SUPERVISOR:

COMPUTER#:

CLEAN ENTRY

DATE & TIME:

BY WHOM:

MESSAGE #:

RADIO
G.B.

DATE & TIME:

BY WHOM:

RPD
A-23
(REV: 12/2006)

BELOW FOR RECORDS USE ONLY

PROCESSED BY:

Q.C. BY:

E-10 BY:

CLASSIFICATION CHANGED:   ☐NO

YES, TO:

ENTERED BY:

PROPERTY BY:

SPECIAL DISTRIBUTION BY:

S DAILY BULLETIN BY:

 

Vehicle Information:

Make:                                Model:                                         Color                                Year:                                 
VIN:                                                   Registration #:                       State:                                              
Owner’s Name:                                                                                                                ☐ Male ☐ Female
DOB:                                 Race:                     Ethnicity:                   (Hispanic or Non-Hispanic)

Street Address:                                                                                       Apt:                                     
City:                                                                         State:                              Zip:                 -___________

 

INSURANCE CARRIER PROVIDING COVERAGE:

NAME & ADDRESS OF INSURANCE CARRIER’S AGENT:

AGENT’S TELEPHONE #:

PLEASE READ WARNING BELOW!

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False Reports to Law Enforcement Authorities: BY SIGNING AND SUBMITTING THIS REPORT TO THE READING POLICE DEPARTMENT I VERIFY THAT THE FACTS SET FORTH HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE OR INFORMATION AND BELIEF. THIS VERIFICATION IS MADE SUBJECT TO THE PENALTIES OF SECTION 4904 OF THE CRIMES CODE OF PA (18 PA.C.S. §4904) RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES.
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Description of What Occurred: (Please attach additional pages if needed)
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MAIL, FAX OR RETURN TO:
Reading Police Dept. 815 Washington Street, Reading, PA 19601-3690
FAX #610-655-6135