Motor Vehicle Theft Report
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1Pacific County Sheriff’s Office
MOTOR VEHICLE THEFT REPORT
P.O. Box 27, South Bend, WA 98586
318 Second N.E., Long Beach, WA 98631
(360) 875-9395 Fax: (360) 875-9393
(360) 642-9403 Fax: (360) 642-2218
1. Reporting Agency
2. Reporting Agency Case Number
3. Estimated Value
4. Date of Theft
5. Time of Theft
6. Location of Theft
7. Vehicle Year
8. Make
9. Model
10. Style
11. Color
12. VIN
13. License Number
14. State
15. Expiration Date
16. Location of Duplicate Keys
17.
Vehicle Loaned : Yes
No
Rented:
Yes
No
18.
Keys in vehicle: Yes
No
Doors Locked:
Yes
No
Note: If vehicle was loaned or rented, describe to whom and by whom, terms of
Damaged:
Yes
No
Paymnets Overdue
Yes
No
agreement (verbal or written and length) in block no. 41 below.
Driveable:
Yes
No
Divorce or Sep in Progress: Yes
No
19. Identifying Characteristics
20. Fuel Inventory
(Damage, Special Equipment, other ID numbers, other points of identity)
21. Insurance Company
(Agent, Address, Phone)
22. Theft Reported By
23. Address
24. Residence Phone
25. Other Phone
26. Registered Owner
27. Address
28. Residence Phone
29. Other Phone
30. Legal Owner / Lienholder
31. Address
32. Residence Phone
33. Other Phone
34. Vehicle Purchased From
35. Address/Phone
36. Date of Sale
37. Has Title Been Transferred?
YES
NO
38. Suspect(s)
39. Address/Phone
40. Physical Description
MALE
FEMALE
Age: ________
Weight: ________ Height:___________
__________
Race:________
Eye:
________ DOB:
41. STATEMENT OF REPORTING PARTY
(Describe Circumstances of Theft) [if additional space is needed, use plain 8.5 x 11 paper for page 2]:
I, THE UNDERSIGNED HEREBY DECLARE THIS INFORMATION TO BE TRUE AND CORRECT: I DID NOT GIVE ANYONE PERMISSION TO TAKE OR
USE THE DESCRIBED VEHICLE (EXCEPT AS DESCRIBED ABOVE); I AM THE OWNER OR PERSON WHO WAS LEGALLY IN POSSESSION OF THE
DESCRIBED VEHICLE AND WILL TESTIFY IN COURT, UNDER OATH, TO THE FACTS HEREIN. IF I REGAIN POSSESSION OF THIS VEHICLE, I
UNDERSTAND THAT I MUST NOTIFY THIS LAW ENFORCEMENT AGENCY IMMEDIATELY OF THE RECOVERY. I ALSO UNDERSTAND THAT I
MAY BE CHARGED WITH A CRIME IF THE INFORMATION LISTED ABOVE IS FALSE.
DATE:
TIME:
SIGNATURE:
_______________________
________________________
____________________________________________________________
LAW ENFORCEMENT ONLY, FILL OUT SECTION BELOW:
42. Sobriety of Complainant
43. Proof of Ownership Shown By:
44. Entered Into WACIC:
Reg
Title
None
Date:
Time:
45. Report Taken by
Pers. No.
Date:
Dist:
46. If Legally Parked When Located:
Impound
Contact Owner
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