THE INFORMATION YOU REQUEST (Check Applicable):

I wish to file a(an):*

Update on Case Suggestion

Inquiry Other

You are: *

Victim Complainant (Employee of Victim)

Other:

CONTACT INFORMATION:

Full Name*

Date of Birth: *

Your Driver’s License/State Id (If available):

Address: *

Home Phone or Cell: *

Work Phone:

Email Address:

INCIDENT DETAILS:

Brief Description of Incidident or Request:*

Location of Incident: *

Date of Incident: *

Time of Incident:

Name of Bensenville Officer/Employee(If known):

Name of Witness(es) or Others Involved (If known):

Witness Address (If known):

Witness Phone:

Statement/Description of Incident/Reason for Request/Additional Info. about Case: