| INCIDENT DETAILS | DATE OF OCC: __________ TIME OF OCC: ________ TIME REPORTED: ________ OFFENSE / COMPLAINT TYPE (Code): ___________ (e.g., Harassment – 240.26)

| DISPOSITION | [ ] COMPLAINT FILED – NO ARREST [ ] REFERRED TO OTHER UNIT (Specify: _______________) [ ] UNFOUNDED [ ] COMPLAINANT REFUSES TO COOPERATE [ ] MISCELLANEOUS / OTHER: _______________________________

| INCIDENT LOCATION | ADDRESS: _____________________________________________ APT/FL: _____ BOROUGH: [ ] M [ ] BX [ ] Bklyn [ ] Qns [ ] SI CROSS ST: _________________ PREMISES TYPE: [ ] RES [ ] COMM [ ] SCHOOL [ ] TRANSIT [ ] STREET [ ] OTHER

| OFFICER INFO | OFFICER NAME (Printed): _______________ SHIELD #: _______ COMMAND: _______ SIGNATURE: _____________________________ DATE: ________

| SUSPECT (If known) | LAST: ____________________ FIRST: _______________ MI: ___ DOB: ___________ (or approx age: _____) SEX: [ ] M [ ] F [ ] X RACE: _____ HT: _____ WT: _____ HAIR: _____ EYES: _____ CLOTHING: ________________________________________ WEAPON: [ ] NONE [ ] KNIFE [ ] GUN [ ] OTHER: _________