INFORMATION FOR POLICE REPORT

CONTACT INFORMATION Name Address Jones (Last Name) 123 Main Street (Street) Frank (First Name) Sacramento (City) C. (Middle Initial) CA 98765 (State and Zip Code)

Home Phone Number Email Address Fax Number

111.111.1111 fjones@abc123.com _________________

PERSONAL INFORMATION Date of Birth Social Security Number Race Sex Height Weight June 24, 1965 Caucasian Male 5' 10" 165lbs.

REPORT INFORMATION Type of Incident: Electronics and other items were stolen from my house.

Following are the types of theft that I was a victim of: X Jewelry X Collectibles X Entertainment Items Date of Incident: April 03, 2012 Time of Incident: 11:00pm How did you become aware of the incident? I came home from a concert and discovered that my door was open and my television was missing. Location of Incident: Sacramento, CA Briefly Describe the Incident: I was away from my house for approximately six hours, from 6:00 to 12:00. When I returned home, I discovered my television and other items were missing. I checked the house further and found my back door had been broken into. Information regarding Thief (please provide any information that you may have about the alleged thief): N/A

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Please list all items that were lost or stolen, using as many unique identifying characteristics as possible. 1. Flat screen television 2. Blu-ray DVD player 3. JVC Stereo receiver 4. PlayStation 3 game console 5. Hugo Boss wristwatch

_____________________________________ Signature

April 12, 2012 Date

This is a RocketLawyer.com Legal Document