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2. Simple Assault, Non-Domestic
   A person is guilty of this offense if they commit an assault on another person.
4. I am the (select one)*

   1. Victim

   1. Witness

   1. Third party
6. First Name*
7. Last Name*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Phone Number including area code:*
18. Email
20. If you are a third party reporting a crime, please state who you are reporting for:
22. First Name
23. Last Name
25. Address1
27. Address2
29. City
30. State
31. Zip
33. Location of Incident/Crime:
35. Common name of place if applicable (ie: Walmart, Trade Wilco, etc.):
37. Address1
39. Address2
41. City
42. State
43. Zip
45. Date and Time Incident occurred*
    Date and Time Incident occurred Start Date

    Date and Time Incident occurred Start Time

    —

    Date and Time Incident occurred End Date

    Date and Time Incident occurred End Time
47. Description of assault
    Include details such as date, time, nature of incident, what what said, sequence of events, etc...
49. Name of suspect
50. Phone Number of Suspect
52. Description of suspect
    Enter here any description you can provide of the suspect (ie: height, weight, race, clothing, age, sex, unusual markings such as tattoos or scars, etc) If known, include name of suspect.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field