Loss Listing Form - Police Supplemental Report

2. INSTRUCTIONS

   This is a supplemental reporting form to be used once you have already filed a report with our agency. In the first column, list the type of item stolen (ie; electronics, jewelry, bikes, etc.) In the middle column, specify the brand/ model/serial #/ color or identification markings. In the last column, indicate the value of the item. At the end of the form you will indicate the TOTAL value of all items listed.

4. POLICE CASE NUMBER
5. OWNER/ REPORTER NAME
6. CONTACT NUMBER
10. Type
11. Brand/ Model/ Serial # / Color
12. Value
14. Type
15. Brand/ Model/ Serial # / Color
16. Value
18. Type
19. Brand/ Model/ Serial # / Color
20. Value
22. Type
23. Brand/ Model/ Serial # / Color
24. Value
26. Type
27. Brand/ Model/ Serial # / Color
28. Value
30. Type
31. Brand/ Model/ Serial # / Color
32. Value
34. Type
35. Brand/ Model/ Serial # / Color
36. Value
38. Type
39. Brand/ Model/ Serial # / Color
40. Value
44. DISCLAIMER;

    Under Florida State Statute 817.49, FALSE REPORTS OF COMMISSION OF CRIMES; PENALTY. 

    (1) Except as provided in subsection (2), whoever willfully imparts, conveys, or causes to be imparted or conveyed to a law enforcement officer or employee of a public safety agency false information or reports concerning the alleged commission of any crime under the laws of this state, knowing such information or report to be false, when no such crime has actually been committed, commits a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083 punishable by a fine up to $1,000 and/or imprisonment not to exceed one (1) year. 

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field