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Name:__________________________________________________________
Address:_______________________________________________________
Home Phone:______________________ Work Phone:______________________
Date: __________________ Time:___________________
Location:__________________________________________________________
Description of watercraft or land vehicle:
Color: __________________ Size:_________________
Make/Model:___________________________
Style: _______________________________
MC# or License Plate #:____________________________
Description of Operators, Driver / Occupants:
Age: ____________ Sex __________ Ht.______________ Wt._____________ Hair Color ____________
Clothing:___________________________________________________________
Description of incident: (as detailed as possible, i.e., speed, direction, distances, sound, parking, obstruction, etc.)
I certify that all statements are true. Signature:____________________________________
Print Name: ___________________________________
I will/will not (circle one) testify in a court of law as the complainant. NOTE: This form will be used as information ONLY in the cases where it is indicated WILL NOT testify.
PLEASE CALL THE MARINE DIVISION AT 248-391-0256
PLEASE CALL THE OAKLAND COUNTRY SHERIFF AT 248-858-5000
For Emergencies CALL 911
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