OFFENSE/INCIDENT REPORT

1. TYPE

INSTRUCTIONS ARE PRINTED SEPARATELY. IF ADDITIONAL SPACE

IS NEEDED, USE REVERSE OF FORM; IDENTIFY ITEMS.
INCEDENT REPORT FORM
2. CODE
NO.

a. ORIGINAL

b. CONTINUATION

3. TYPE OF OFFENSE OR INCIDENT

2a. SORT

c. SUPPLEMENT
OR FOLLOWUP

4. CASE CONTROL NUMBER

Speeding/Wreckless Driving

5. BUILDING NUMBER

6. ADDRESS

7. NAME OF AGENCY/BUREAU

8. SHERIFF UNIT NUMBER

West BeaverHead Ave

Adam District

9. SPECIFIC LOCATION

6A-8

11a. DATE OF OFFENSE/INCIDENT

11a. TIME OF OFFENSE/INCIDENT

04/17/2016
15. JURISDICTION (X)

VEDINVOLNSPERSO18.

ID
CODE
(a)

12.
DAY

2105

EXCLUSIVE

10. LOCATION POSTAL

CODE

West BeaverHead Ave

4100

13a. DATE REPORTED

16. NO. OF DEMONSTRATORS

CONCURRENT

PARTIAL

17. NO.
EVACUATED

PROPRIETARY

0
AG
E
(c)

NAME AND ADDRESS

(b)
Last Name, First, Middle Initial

50

Darwin Schultz

SE
X
(d)

a. TIME START

b. TIME END

2105

2120

RA
CE
(e)

INJURY
CODE
(f)

n/a

BUSINESS

Number, Street, Apt. No., City and State

2000

a. STATUS

STOLEN

BUSINESS

c. MAKE

g.
REGISTRATIO
N

GOVT

PERSONAL

VANDALIZ
ED

RECOVERED

d.
MOD
EL

pmp600

e. COLOR (Top/Bottom)

f. IDENTIFYING CHARACTERISTICS

green

SUSPECT

YEA
R

STAT
E

TAG
NO.

200
0

SA

rpc82
64

h. VIN

i. VALUE

14ffg54g1d2e

a. NAME OF ITEM

b. QUANTITY

n/a

n/a

e. SERIAL NO.

f. COLOR

g. MODEL

n/a

na

n/a

i. UNUSUAL OR UNIQUE FEATURES

na

n/a

j. PROPERTY WAS

k. STATUS OF PROPERTY

SECURRED
UNSECURED

RECOVERED

c. OWNERSHIP
GOVT

h. VALUE

PERSONAL

d. BRAND NAME

n/a

VALUE RECOVERED
MISSING

PARTIAL RECOVERY

l. NAME OF ITEM

m. QUANTITY

p. SERIAL NO.

q. COLOR

r. MODEL

t. UNUSUAL OR UNIQUE FEATURES

u. PROPERTY WAS

v. STATUS OF PROPERTY
RECOVERED

n. OWNERSHIP
GOVT

s. VALUE

SECURRED
UNSECURED

HOME

b.
YEAR

19. VEHICLE
TAKEN 20. ITEMS

TELEPHON
E
(g)
HOME

1880 briddger st

14. DAY

Number, Street, Apt. No., City and State

Last Name, First, Middle Initial

13b. TIME REPORTED

PERSONAL

o. BRAND NAME

VALUE RECOVERED
MISSING

PARTIAL RECOVERY

21. NARRATIVE (If additional space is needed, use blank sheet and attach.)

Mr Schultz was speeding on Beaverhead ave passed on a red Light. Mr Schultz pulled over at 4100 Beaverhead as I approached
the car he took off on a long pursuit after 15 minutes Mr Schultz pulled over at union drive west,nohol. Mr. Schultz was detained and
taken into custody at 2120 hrs and arrived at LEFTWOOD police station(4122) at 2123 hrs
.

INCIDENT REPORT FORM

GSA FORM 3155 (REV. 3/200)

23a. EVIDENCE

TIME

22.
NOTIFICATION

NOTIFIED

YES

ARRIVED

a. Other Police
Agency

0905

0907

b. Fire
Department

c. Ambulance

NO

23b. TAG NO.

23c. TYPE

23d. WHERE STORED

24. ATTACHMENTS (Mark X where applicable)

a. CONTINUATION SHEET
b. GSA FORM 3157
c. PROPERTY RECEIPT(S)

d. STATEMENT(S)

e. SUPPLEMENTAL

f. OTHER ATTACHMENTS (Specify)

d. Building
Manager

e. OTHER
(Specify)

25. SUSPECT STATUS

26. DISPOSITION OF SUSPECT

a. NOT IDENTIFIED

a. ARRESTED

b. GOVERNMENT EMPLOYEE

c. RELEASED

c. GOVERNMENT CONTRACT

d. NON-GOVERNMENT EMPLOYEE

b. NOT ARRESTED

d. N/A

CITATION NUMBER

d. CITATION ISSUED

e. N/A

NOTE: Complete GSA Form 3157 where this is a Suspect, Att. Burglary, Burglary, Att. Robbery, Robbery, or a Weapon is used.
27. TIME
a. RECEIVED

28. REVIEWED BY

b. ARRIVED

a. TYPE
FPS

c. RETURNED TO SERVICE
29a. BADGE

b. SIGNATURE

d. DATE

c. NAME (Printed)

GG

29b. NAME (Printed)

29c. SIGNATURE

29d. DATE

30. CASE REFERRED TO

a. DETECTIVE

b. POLICE

c. SHERIFF

d. ICE

e. TRAFFIC

f. N/A

g. OTHER (Specify)

31. CASE

32. APPROVING OFFICIAL

a. SIGNATURE

b. DATE

a. OPEN

b. CLOSED

c. NAME (Printed)

c. UNFOUNDED

33. DETECTIVE STATUS

a. CASE NUMBER

b. HOW CLOSED
INACTIVE
MEANS

c. SUSPECT
ARREST

OTHER

f. VALUE OF PROPERTY
e. PROPERTY
RECOVERED

d. ENTERED NCIC

DEVELOPED

ARRESTED

g. CLEARED NCIC

YES
h. REFERRED TO

YES

NO

N/A

i. DATE REFERRAL ACCEPTED

21. NARRATIVE (If additional space is needed, use blank sheet and attach.)

NO

N/A

GSA FORM 3155 (REV. 3/200) PAGE 2