Police Involvement Report

POLICE INVOLVEMENT REPORT

This Police Involvement Report (the Report) is made as of Effective Date: by and between Reporting Party: whose address is and Law Enforcement Agency: represented by Officer: Badge No.: .

RECITALS

WHEREAS, Reporting Party reports an event or interaction involving law enforcement described herein and requests that such event be recorded; and

WHEREAS, Law Enforcement Agency has responded, investigated, or otherwise engaged in actions related to the event and intends to document the facts, actions taken, evidence collected, and official statements; and

WHEREAS, the parties desire to memorialize the incident details and the respective certifications and releases in a form suitable for administrative, investigative, and legal purposes.

NOW, THEREFORE, in consideration of the mutual covenants and promises set forth below, the parties agree as follows:

1. INCIDENT DETAILS

Date of Incident:    Time of Incident:

Assault    Theft/Burglary    Traffic Collision    Domestic Incident    Other (specify):

2. PARTIES AND WITNESSES

3. POLICE RESPONSE AND ACTIONS TAKEN

Officer(s) on Scene:    Arrival Time:

Arrest made    Citation issued    Warning issued    Medical assistance provided    Use of force (describe below)

4. EVIDENCE AND PROPERTY

5. STATEMENTS

6. CERTIFICATIONS, RELEASES, AND CONFIDENTIALITY

Reporting Party hereby certifies, under penalty of perjury, that the information set forth in this Report is true and accurate to the best of Reporting Party's knowledge and recollection. Reporting Party understands that knowingly submitting false information may be subject to criminal penalties.

Law Enforcement Agency certifies that the information contained herein reflects the agency's documented response, observations, and action as recorded by its personnel. The agency further represents that it has complied with applicable retention, evidence-handling, and reporting protocols.

Reporting Party authorizes disclosure of this Report and any attached statements or evidence to courts, prosecutors, defense counsel, and other authorized entities for investigatory or judicial purposes. Reporting Party may indicate limitations on disclosure by initialing here:

7. NOTICES

All notices required or permitted under this Report shall be made in writing and delivered to the addresses below. Notice to Reporting Party:

Notice to Law Enforcement Agency:

8. GOVERNING LAW

This Report and any dispute arising out of or related to this Report shall be governed by and construed in accordance with the substantive laws of the jurisdiction where the incident occurred, without regard to conflict-of-law principles.

9. ENTIRE AGREEMENT

This Report constitutes the entire written record of the parties' statements, certifications, and acknowledgements with respect to the incident described herein and supersedes all prior written or oral communications concerning such incident to the extent they relate to the matters addressed in this Report.

10. SEVERABILITY

If any provision of this Report is held to be illegal, invalid, or unenforceable under present or future laws, such provision shall be fully severable and this Report shall be construed and enforced as if such illegal, invalid, or unenforceable provision had never comprised a part hereof.

11. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment to this Report shall be effective unless in writing and signed by both parties. Failure by either party to enforce any provision shall not be deemed a waiver of future enforcement of that or any other provision. This Report may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

12. ATTESTATION

Each signer below certifies that he or she is authorized to execute this Report on behalf of the party indicated and that the information provided above is true, complete, and accurate to the best of the signer's knowledge.

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