SUPPLEMENTARY

INCIDENT REPORT	ATLANTA POLICE DEPARTMENT	Page of

NARRATIV

E

AFFIDAVIT

Incident / CICA No.

2. Complainant Name: (L,F,M, Suffix / Business)

3. Date of Report:

Reserved:
THE UNDERSIGNED, BEING DULY SWORN, UPON HIS OR HER OATH, DEPOSES AND STATES THAT THE FOREGOING IS TRUE, CORRECT, COMPLETE AND LEGIBLE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF.

6. Referred to: RD HR Vice Hom Burg Youth

Zone FV Fug SD Sex Larc PS2

AHA CP Narc SIS Rob AT	7. Reporting Officer’s Signature	8. APD ID No.

9. SWORN TO AND SUBSCRIBED BEFORE ME

THIS ______ DAY OF _____________________________, 20_____
10. Reviewer’s Signature

11. APD ID No.

.	12. Supervisor’s Signature

13. APD ID No
Incident/CICA No.
SUPPLEMENT (back)
FAMILY	VIOLENCE	DATA
1. Source Name: (L/F/M,Suffix) Victim Primary Agg

2.Were children

involved?

Yes No	3. Act commited

with children present?

Yes No	4. Previous Complaints:

A Zero C 6-10 U Unknown
B 1-5 D More than 10
5. Existence of prior court orders indicated Yes No Unknown

6. Victim advised of available remedies and services Yes No
7.Type of Alleged Abuse: 01 Fatal Injury 02 Perm Disability 03 Temp Disability 04 Broken bones 05 Gun/Knife

06 Superficial Injury 07 Property Damage/Theft 08 Threats 09 Abusive Language 10 Sexual Abuse 11 Other	Police Action Taken

9. Reason No

Arrest Made:	1 Juvenile 2 Primary Aggressor not at scene

3 Insufficient Probable Cause 4 Other List :	10. Primary Agg. 1 Physical Evidence 3 Other List

Identified by: 2 Testimonial Evidence
11. Substance abuse involved

Primary Agg: 1 Drugs

Victim: 1 Drugs	Yes No Indicated substances used:

2 Alcohol 3 Combination of drugs & Alcohol

2 Alcohol 3 Combination of drugs & Alcohol	12. RelationshipPresent Spouse 5Stepparent 3Parent 4Child

of the parties: 2 Former Spouse 3 Stepchild 7 Foster Parent

8 Foster Child 9 None of the above, but live in same household.
Vehicle Data
2. Owner Name: (L/F/M, Suffix)

Address: (Street #, street name, Apt. #, City St., Zip

3. Work Phone

4. Driver Name: (L/F/M, Suffix)

5. Is Driver Owner? Yes No

Driver Arrested? Yes No	6. Record Type : S Stolen T Theft from vehicle

R Recovered V Suspect Vehicle

D Damaged Other	8. Home Phone

Vehicle Type:*

Year

Make

11 Model

12. VIN #

13. Vehicle

14. Color

15. Tag Number

16. State

17. Year

18. Tag Type*,

19. Locked? Yes No

Ignition Locked? Yes No

Keys in Ignition? Yes No
20. Date Lost/ Stolen

/ /	21. Stolen Veh. Value

$	22. Recovered Veh. Value

$	23. Vehicle Reported Stolen In Atlanta Outside	If out, jurisdiction:

Vehicle Data
2. Owner Name: (L/F/M, Suffix)

Address: (Street #, street name, Apt. #, City St., Zip

3. Work Phone

4. Driver Name: (L/F/M, Suffix)

5. Is Driver Owner? Yes No

Driver Arrested? Yes No	6. Record Type S Stolen T Theft from vehicle

R Recovered V Suspect Vehicle Other	7. Home Phone

Vehicle Type:*

Year

Make

11 Model

12. VIN #

13. Vehicle Style

14. Color

15. Tag Number

16. State

17. Year

18. Tag Type*,

19. Locked? Yes No

Ignition Locked? Yes No

Keys in Ignition? Yes No
20. Date Lost/ Stolen

/ /

21. Stolen Veh. Value

$	22. Recovered Veh.

Value $	23. Vehicle Reported Stolen z In

Atlanta Outside	If out, jurisdiction:

PROPERTY DATA
Check appropriate block:	INCIDENT PROPERTY DATA	ADDITIONAL LOSS / RECOVERY REPORT
RECORD TYPE: A - Additional Loss

D - Damaged L - Lost

R - Recovered S - Stolen,	PROPERTY TYPE: G - Electronics

B - Currency C - Jewelry E - Clothing F - Office Equipment

H - Household Goods I - Firearms J - Consumables L - Other,	PROPERTY STATUS:

F- Found R - Returned

N/A - Not in Possession of Atlanta Police
1. Record Type	2. #QUANTITY/DESCRIPTION

Make -Model-Identifying Feature	3. Property

Type	4. Serial No. or Identifying No.	5. Estimated

Value $ Amt.
#
#
#
#
#
#
#
#
#
NOTE: If Additional Loss / Recovery Report, Complete items 7 through 12 below:
7. Owner Name: (L/F/M, Suffi) Address: (Street #, street name, Apt. #, City St., Zip),

8. Work Phone

9. Location Items Found / Recovered: Address: (Street #, street name, Apt. #, City St., Zip)

10. Home Phone

11. Recovered By: (Name)

12. Custody ((If different than owner),

APD FORM 002 (front and back) Revised 10/30/00

SUPPLEMENTARY

VWarnic

2000-11-02

Atlanta Police Department