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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