-7

---nr.o 'n...........' ..... , nil III a" ....lIIf1R7l1"1y til> pUDl>IO't:; lrdlUt:lli (WI nli,JJNfl vaJUtf. ~ ITWI1IleW ~AN fA MONIGAPOLICE DEPARTMENT name is listed, state briefly what he observed. If there is sufficient information, as definite suspect, license number, or if loss is over $400.00, do not use this form. Notify the Officer. DROP-OFF REPORT (If Officer cannot be contacted, call Police station). If a business, give business name.

PLEASE PRINT OR TYPE· USE BLACK INK

Theft: J8LFrom Auto D Auto Access D Petty D Nul88nce, Malicious Mischief Loss: D Jewelry 0 Purse D Other (specify): o Other (specify):

DATE CRIME REPORTED TO POLICE DEPT. TIME 0 I B1Gn.

RACE,?~a1eDMale

SEX

RESIDENCE PHONE NUMB£ • BUSINESS PHONE NUMBER

(-;It:i)fpf3- s-I C31v) <tk~!J"1"cJS""X.

('1;" )

TIME

:)h, REPORTING DISTRICT

o·;Z) 0 .m. o am. DAY OF WEEK CRIME OCCURRED

D p.m. iI1iP"ld. TYPWF PREMISeS WHERE1HEFT OCCURRED (HouM. ~ .teo)

~~J~n . ~~ (f'kJ,__/

BUSINESS PHONE NUMBER

(1/0 )5''-11;. ~-S5.,7rt CITY Z1PCOOE

RESOENCE PHONE NUMBERNAME OF WITNESS - LuI. Am, Middle BUSINESS PHONE NUMBER

x CITYRESIDENCE ADDRESS ZIPCOOE

AUTO l.OCt<ED?

DYes ONo

::\:':':::::::::)::::U:::t()):(:):})::::::tII))::::))it'i'i'i)i:::}:::'it{('i:::::)::t)it::Q~lQN.:Q.fin.i&):)))))t))):::::})):))ft'{)%ttti'i'i:::)/):)::)t::))):}:)i(::/:::,;:;;::)t)",,:

Write a brief paragraph describing circumstances of how theft or loss, occul'lll.4. TI'MH1 deeeribe full~q,ach item 1aken {brand name, color, etc.). Give serial number. marks of ide, tification andf)l'8S8f1trnarltet vaTue.· oet9rmlne actual cash value of each article (not sentimental value).

-L , 114.

o ::a ....

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