Arlington Police Department

Please check this box to remain anonymous, otherwise a name and email address or phone number is required.

Traffic Stop?

Your Name:

Date Of Birth:

Email:

Your Address:

Home Phone:

Your Employer:

Business Phone:

Incident Date:

Address Where Incident Occurred:

1.

2.

3.

4.

Have you reported this to other officers?

Yes

No

If so, whom?

Did you receive a citation(s)?

Yes

No

Number and reason?

Were you arrested?

Yes

No

Reason?

Do you have a police report number for this incident?

Yes

No

Number?

Do you know the police car number?

Yes

No

Number?

Name:

Address:

Phone:

Name:

Address:

Phone:

Name:

Address:

Phone:

Name:

Address:

Phone:

PLEASE READ BEFORE SUBMITTING
I understand that it is a violation to willfully make a false report. In the event this report is proven false, the information may be provided to the District Attorney or City Prosecutor for possible prosecution.

By clicking the Submit button I certify that the statements in this form are true.

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