2. THE INFORMATION YOU REQUEST (Check Applicable):
4. I wish to file a(an):*

   1. Update on Case
   2. Suggestion

   1. Inquiry
   2. Other
5. You are: *

   1. Victim
   2. Complainant (Employee of Victim)

   1. Other:
7. Contact Information
9. Full Name*
10. Date of Birth*
12. Your Driver’s License/State Id (If available):
13. Email Address
15. Street Address:*
17. Phone Number*
18. Work Phone:
20. INCIDENT DETAILS:
22. Brief Description of Incidident or Request:*
24. Location of Incident:*
25. Date of Incident:*
27. Time of Incident:
28. Name of Bensenville Officer/Employee(If known):
30. Name of Witness(es) or Others Involved (If known):
31. Witness Address (If known):
33. Witness Phone:
35. Statement/Description of Incident/Reason for Request/Additional Info. about Case:*
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

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