Form Mv-104l - Report Of Motor Vehicle Accident Police Line Of Duty Accident
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1REPORT OF MOTOR VEHICLE ACCIDENT
POLICE LINE OF DUTY ACCIDENT
o
AMENDED REPORT
Page
of
Pages
Precinct
IMPORTANT: If you are the officer in charge, complete and sign
Local Accident Number
this form, and attach it to the MV-104A or MV-104AN.
Accident Date
Accident Time
County
In
/
/
Military
Month
Day
Year
Time
NAMES OF DRIVERS: (Please Print or Type)
Check the box below if the vehicle was operated by a police officer during emergency operation (as defined by
Vehicle and Traffic Law Section 114-b) when the accident occurred. If the officer(s) was not charged with a violation
or found to be grossly negligent, DMV will not display the accident on the police officer’s license abstract pursuant
to Section 605(a)(4) of the Vehicle and Traffic Law.
State
Driver
Driver
Plate
of Veh.
License
License
Reg.
State
Number
Last
First
M.I.
Number
VEH 1
o
VEH 2
o
VEH 3
o
VEH 4
o
VEH 5
o
VEH 6
o
Pursuant to Section 605 of the New York State Vehicle and Traffic Law, the attached Police Accident Report
is also the motorist report for vehicle number(s) ______________________.
Date
Signature of Owner of Police Vehicle/Police Agency Representative
NCIC #
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MV-104L (5/15)
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