| NATURE OF ACTIVITY | | |
| Today's Date: |
I am reporting...
| If Insurance Fraud, please be sure to complete the
INSURANCE FRAUD SECTION below. | |
| POLICE CONTACT | | |
| Have you contacted the police? | If yes, which Police Department?
| |
| | If other, please complete, | |
| | | |
| | Date:
| |
| Did you work with a specific officer? | If yes, what was the name of the Officer?
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| What is the Officer's phone number? | |
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| Has anyone been arrested? | | |
| Complaint number, if known: | | |
| WHERE/WHEN CRIME OCCURRED | | |
| When did you observe the activity/crime? | Date:
and | |
| | Approximate Time: | |
| What city did the crime occur? | | |
| What is the address or cross streets where the crime occurred? | | |
| Is the location a | | |
| SUSPECTS | | |
| Name(s) of the person(s) involved: | | |
| Suspect #1 | Suspect #2 | |
| Last Name: | | |
| First Name: | | |
| Middle Name/Initial: | | |
| Alias/Street Name: | | |
| Address: | | |
| City: | | |
| Zip: | | |
| DOB/Age: | | |
| Sex: | | |
| Height: | | |
| Weight: | | |
| Eyes: | | |
| Hair: | | |
| Race: | | |
| Other Features: Check all that applies. | | |
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| What is the relationship with Suspect #1? | |
| DESCRIPTION OF THE VEHICLE(S) | | |
| Description of the vehicle(s): | | |
| Vehicle 1 | Vehicle 2 | |
| Year: | | |
| Make: | | |
| Model: | | |
| Color: | | |
| Body Style: | | |
| Where is the vehicle located? | | |
| | | |
| H.E.A.T. PROGRAM | | |
| Have you previously reported a tip through HEAT? | | |
How did you hear about the HEAT Program?
| If other, please specify:
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Is there any other information you'd like to give?
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| INSURANCE FRAUD SECTION | | |
| Is the suspect: |
BACK | |
| |
|
| Has the owner reported the vehicle stolen to his/her insurance company? | |
| Name of the insurance company, if known: | |
| Name of the contact person at that company? | |
| Contact person phone number? | |
| Policy number, if known: | |
Please provide the circumstances of the fraud:
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| OTHER INFORMATION (NOT REQUIRED BUT HELPFUL!) | | |
If the investigating agency determines that your tip was helpful in the arrest and recovery,
you may be eligible to receive a reward and the police agency will need a way to contact you.
|
Would you like to leave your name, or do you wish to remain anonymous?
| Name: | |
Would you like to leave your phone number?
If yes, please begin with the area code. | Home Phone: | |
| | Work Phone: | |
| | Cell Phone: | |
| | Pager: | |
| | Other: | |
| | If other, please specify (parent's home, friend, etc.)
| |
| Is it okay if a police officer contacts you if they need more information? | | |
| If okay, which phone number? | | |
| Who should they ask for? | | |
| Is it OK to leave a message if you're not there when they call? | | |
| If yes, which number? | | |
| Would you like to leave your address? | Street Address: | |
| | Apt: | |
| | City: | |
| | Zip: | |
| | County: | |
| | E-Mail Address: (Not Required) | |
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| HEAT (Rev.2011) | |
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