Stolen Vehicle Report
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1STATE OF CONNECTICUT
STOLEN VEHICLE REPORT
DEPARTMENT OF MOTOR VEHICLES
H-108 REV. 8-2001
On The Web At
INSTRUCTIONS:
The owner of any motor vehicle stolen in this state must make a report in writing to the office of the local or
CASE NUMBER
State Police in the municipality in which the theft occurred. (C.G.S. 14-151a(a)). The filing of this report in
P.D.
accordance with the above, is required by C.G.S. 14-151a(b) prior to settlement of any insurance claim.
USE
A person who knowingly makes a false report of the theft of a motor vehicle to a Police Officer shall be fined
NOTICE:
NCIC NUMBER
ONLY
five hundred dollars or imprisoned for not more than six months or both in accordance with Section 14-198 of
the Connecticut General Statutes.
NAME OF POLICE DEPARTMENT
DATE REPORTED
I hereby report to the following Police Department
that the vehicle described below was stolen.
YEAR
MAKE
MODEL
BODY STYLE
COLOR(S)
VEHICLE
MARKER PLATE NUMBER
VEHICLE REGISTERED?
IF YES, IN WHAT STATE?
VEHICLE IDENTIFICATION NUMBER
NO
YES
INFORMATION
ESTIMATED VALUE OF VEHICLE
WERE DOORS LOCKED?
WERE KEYS IN VEHICLE?
NAME OF INSURANCE COMPANY
YES
NO
YES
NO
$
NAME OF OWNER
TELEPHONE NUMBER
OWNER
ADDRESS
INFORMATION
WILL OWNER OR PERSON IN CUSTODY OF VEHICLE BE AVAILABLE FOR COURT?
YES
NO
DATE VEHICLE STOLEN
DAY OF WEEK
TIME
LOCATION STOLEN FROM (Street,, etc.)
A.M.
P.M.
INCIDENT
INFORMATION
REPORTED STOLEN BY (Name)
ADDRESS
TELEPHONE NUMBER
SIGNATURE (Person filling out report)
DATE SIGNED
SIGNATURE
X
DO NOT WRITE BELOW THIS LINE - POLICE DEPARTMENT USE ONLY
REPORT TAKEN BY (Name of Officer)
BADGE NUMBER
POLICE DEPARTMENT
POLICE DEPARTMENT NAME
Local
State
DATE REPORT FILED
TIME FILED (Military)
NCIC ENTERED
TIME ENTERED (Military)
NCIC OPERATOR
OFFICER'S
ADDITIONAL INFORMATION (Continue on back if necessary)
REPORT
DATE OF RECOVERY
TIME (Military)
RECOVERY LOCATION
NAME OF RECOVERY OFFICER
WAS VEHICLE TOWED?
IF YES, BY WHOM (Name and address)
WHO AUTHORIZED TOW?
YES
NO
WAS ARREST MADE?
WAS OWNER NOTIFIED?
DATE OWNER NOTIFIED
TIME NOTIFIED (Military)
NOTIFYING OFFICER (Name)
YES
NO
YES
NO
RECOVERY
REPORT
WAS NCIC CANCELED?
DATE CANCELED
TIME CANCELED (Military)
NCIC OPERATOR
YES
NO
NAME AND ADDRESS OF PERSON CLAIMING VEHICLE
LICENSE NUMBER (State and Number)
SIGNATURE OF PERSON CLAIMING VEHICLE
DATE SIGNED
X
MISSING
DAMAGED
MISSING
DAMAGED
DAMAGED
YES
NO
PARTS
SECTIONS
LOCKS
BURNED
(x)
(x)
(x)
(x)
(x)
(x)
(x)
TIRES
FRONT
IGNITION
MOTOR COMP.
ENGINE
R. SIDE
DOOR
PASS. COMP.
CONDITION
TRANS.
L. SIDE
TRUNK
TRUNK COMP.
ON
INS. PANEL
REAR
GAS CAP
TOTAL
RECOVERY
SEATS
HOOD
RADIO
FIRE DEPT. RESPONSE
DRIVEABLE
DISTRIBUTION: Part 1- State or Local Police
Part 2 - Individual Making Complaint
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