SILVER ALERT CRITERIA 1. The person must be 18 years of age or older. 3. There must be enough descriptive information to believe the broadcast will help.

2. The person must be a Missing Endangered Adult or High Risk Missing Person or have a mental 4. Request must be recommended by the law enforcement agency of jurisdiction.impairment validated through a credible medical authority.

* 5. Enter the person into IDACS/NCIC with message key EME.

Date Received: Time Received: Date Activated: Time Activated: 1

SA-

(ISP USE ONLY) Alert Approved:

(ISP USE ONLY) Alert Cancelled: Date Received: Time Received: Date Cancelled: Time Cancelled:

Enter the Missing Person into IDACS/NCIC immediately. Call the Clearinghouse as soon as possible to confirm criteria is met.

Current Date: Current Time:

Section A: Law Enforcement Agency Information

1. Requesting Agency 2. Agency Case Number 3. Agency 24/7 Telephone Number (Available to receive leads and media requests)

Section C: Disappearance Information 30. . Date of Disappearance (mm/dd/yy) 31. Time of Disappearance 32. Location/Address of Disappearance

33. City 34. State 35. ZIP code 36. County Indiana

Section D: Reporting Person Information 37. Last Name 38. First Name 39. Middle Name 40. Alias/Maiden Name 41. DOB (mm/dd/yy) 42. Age 43. Cell Phone Number

Section E: Medical Authority

Section G: Vehicle Information 58. Color 59. Year 60. Make 61. Model 62. Type 63. License Plate 64. License Plate State 65. Distinguishing features

4. Investigating Officer Rank/Title 5. Last Name 6. First Name 7. Investigating Officer Phone Number 8. Investigating Officer E-mail

44. Relationship to Victim 45. Address 46. City 47. State 48. ZIP 49. County

50. Title 51. Last Name 52. First Name 53. Telephone Number

am pm

***Agency must receive VERBAL confirmation from a Medical Physician, Physician's Assistant, or Nurse Practioner to attest to one of the following*** (Check at least one) Due to mental impairment, the individual can not find his or her way back to their residence without assistance from law enforcement. Due to physical or mental impairment, or lack of medication, this individual could be a danger to themselves or others. Due to physical or mental impairment, or lack of medication, this individual if driving could be a danger to themselves or others.

Section B: Victim Information # of * Add additional victims on next page9. Last Name 10. First Name 11. Middle Name 12. Alias/Maiden Name 13. DOB (mm/dd/yy) 14. Age 15. Cell Phone Number

27. Scars/Marks/Tattoos/Piercings 28. Description of Clothing (Outerwear, shirt, pants, shoes)

16. Race 17. Gender 18. Height 19. Weight 20. Hair Color 21. Eye Color feet inches pounds

29. Victim in need of medical attention? (Explain)

22. Address 23. City 24. State 25. ZIP code 26. County

Section H: Summary of Disappearance Include any pertinent information not addressed on this form.

IDACS Number: NCIC Number:

INDIANA SILVER ALERT REQUEST State Form 56262 (12-17) Indiana Clearinghouse for Information on Missing Children & Missing Endangered Adults Telephone: 800-831-8953 / Website: http://www.in.gov/isp/2333.htm E-mail: ClearinghouseAlerts@isp.in.gov

*LAW ENFORCEMENT USE ONLY*

Once confirmed, complete the form and e-mail the form and images to ClearinghouseAlerts@isp.in.gov

Physician, Physician's Assistant, or Nurse Practitioner (See Section E below)

Section F: Investigating Agency Representative who contacted Medical Authority54. Title 55. Last Name 56. First Name 57. Telephone Number / Email Address

1. The person must be 18 years of age or older. 3. There must be enough descriptive information to believe the broadcast will help.2. The person must be a Missing Endangered Adult or High Risk Missing Person or have a mental 4. Request must be recommended by the law enforcement agency of jurisdiction.

impairment validated through a credible medical authority. *Physician, Physician's Assistant, or Nurse Practitioner 5. Enter the person into IDACS/NCIC with message key EME.

2

Section I: Additional Victim Information # of Last Name First Name Middle Name Alias DOB (mm/dd/yy) Age Cell Phone Number

Scars/Marks/Tattoos/Piercings Description of Clothing (Outerwear, shirt, pants, shoes)

Section J: Additional Victim Information # of Last Name First Name Middle Name Alias DOB (mm/dd/yy) Age Cell Phone Number

Scars/Marks/Tattoos/Piercings Description of Clothing (Outerwear, shirt, pants, shoes)

Race Gender Height Weight Hair Color Eye Color feet inches pounds

Medical Authority Title Last Name First Name Phone Number Victim in need of medical attention? (Explain)

Race Gender Height Weight Hair Color Eye Color feet inches pounds

Medical Authority Title Last Name First Name Phone Number Victim in need of medical attention? (Explain)

Address City State ZIP County

Address City State ZIP County

SILVER ALERT REQUEST FORM State Form 56262 (R / 3-17) Indiana Clearinghouse for Information on Missing Children & Missing Endangered Adults Telephone: 800-831-8953 / Website: http://www.in.gov/isp/2333.htm E-mail: ClearinghouseAlerts@isp.in.gov

*LAW ENFORCEMENT USE ONLY*SILVER ALERT CRITERIA