Temecula Police Department - Counter Traffic Collision Report Form (Page 2 of 5) in pdf

Temecula Police Department - Counter Traffic Collision Report Form Page 2

For Police Department

use only:

File#___________________

Officer_________________

Temecula Police Department

Counter Traffic Collision Report

1. Your name:__________________________________________________________

2. Your driver’s license number:__________________Date of birth:____________

3. Your home address:___________________________________________________

4. Your telephone number: (Home)___________________(Work)_______________

5. Date of collision:___________________Day of week:________________________

6. Time of collision:________________AM__________________PM

7. Your vehicle license plate number:__________________________

8. Your vehicle’s year, make, model and color_______________________________

________________________________________________________________________

9. Describe the damage to your vehicle:_____________________________________

________________________________________________________________________

10. Was your vehicle:

Parked

Stopped in Traffic

Moving

11. What street or road were you on?______________________________________

________________________________________________________________________

12. What direction were you traveling? (circle one) North South East West

13. What was the nearest cross street?_______________________________________

Temecula Police Department - Counter Traffic Collision Report Form Page 2