committed by (checklist):

___Police Officers
___Attorneys
___Judges
___Other Government Employees
___Business Organizations - Business Employees
___Property Owners/Renters
___Academic Officials, Employees, or Students
___Other Non-government Organizations/Personnel

acting under color of law, or putatively occupying
their positions under color of law, or both.

1. Date of incident/offense:
_______________________________
2. Time of incident/offense (A.M.)(P.M):
_______________________________
3. Location of offense (street address or
commonly known building, location, etc):
_________________________________________________________
3a. City, State, Country:
_________________________________________________________
4. Identity of apparent offender (eg. name, ID#)
_________________________________________________________
4a. Address
_________________________________________________________
4b. Offender's employment position:
_________________________________________________________
operating under color of law.

5. Name of offender's organization:
_________________________________________________________
operating under color of law (Note: The organization
may be regarded as a separate offender).

6. Brief description of what the offender(s) did.

_________________________________________________________
_________________________________________________________
_________________________________________________________

7. Code violations:
_________________________________________________________

8. Physical description of offender: Height, Weight,
Gender, Color, Color Hair, Color Eyes, Clothes, Age:
_________________________________________________________
_________________________________________________________

9. Declaration: My name is
_________________________________________________________
and I declare under penalty of perjury that the
statements submitted in this form are true to the
best of my knowledge, information, and belief.

10. Today's Date:
_________________________________________________________

Note: This citation may be supplemented with a more
extensive report and may be forwarded to the office of the
the Attorney General. If further legal action is taken,
the offender may be subject to summons or arrest.