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M.P.

D FORM 100
(Rev. 5-00)
CALEA 42.2.4, 82.2.1, 82.2.4
Incident Report
Metropolitan Police Department
Nashville, Tennessee
1. MPD Incident No.
Part 1 Incident
2. Related Incident
3. Other Police Agency & Case Incident No.
4. Report Type 6. Incident Date/Time (From/To)
-
13. Weapon CODE
(Enter up to 3)
17. (For Burglary)
Forced Entry
16a. Terrorism
Suspected
18. (For Burglary/Robbery)
Home Invasion?
15. Hate Crime
Suspected
16. Suspected
Gang Activity
If Hotel/Motel/rental Storage
No. of Premises Entered
Part 2
Victim
31. Victim Type 19. (Last, First, Middle Name or Business Name)
Same as Address
of Incident
(Block #8)
22. Address of Victim Street
29. Phone Numbers
HM: WK:
Cell/
Pager:
30. Victim of Offenses:
(Ref Block #9)
34. Domestic
Disturbance?
If Yes, Answer
the Following
Questions
Was Order of
Protection
Violated?
Was Victim
taken to
Safe Place?
Were Children
taken to
Safe Place?
Were Children
Present During
Incident?
36. Aggravated Assault/Homicide Circumstances 37. Negligent Manslaughter 38. Justifiable Homicide
ZONE
233
R.P.A.
1437
2013-0056640
N/A
N/A
8. Address of Incident
EVELYN AVE
DISPATCHED
5. Report Date/Time
01/19/2013 21:07
01/19/2013 19:20 01/19/2013 19:20
UNK
7. Reporting/Dispatched Location
1633 EVELYN AV
Cross Street:
Apt No City State
TN
Zip Code
Cross Street:
Apt No City
NASHVILLE
State
TN
Zip Code
37216
V
Same as Block No 7
Precinct
East Precinct
# 1
9. Offense CODE
740
10. Offense Description
MATTER OF RECORD
11. Status
COMPLETED
12. Location Type CODE
RESIDENCE, HOME
HANDGUN
NO NO NO
No.
1
N/A
Government
UNK MNI
UNK
Cross Street
Apt No City State
TN
Zip Code E-Mail Address
740
N/A
35. Victim to Suspect 1 Relationship VICTIM WAS OTHERWISE KNOWN
Part 3
92. (Last, First, Middle Name) 94. SSN or Driver Lic. No.
97. Sex 98. Race 99. Ethnicity 101. Age
-
Yrs
104. Height
' "
lbs
102. Suspected of Using 103. Status (Enter up to 2)
96. Weapon/Tool
(Enter Up To 3)
110. Vehicle Used
Part 4
Other Person #
39. Other Person Type (Non-Victim) 40. (Last, First, Middle Name)
43. Status 44. Sex 45. Race 46. Age
- Yrs
48. Phone
Numbers
Part 5 Property
49. Victim/Suspect No.
51. Property Description
(Make) (Model) (Size) (Type) (Color)
Suspect # 1
Alias UNK MNI 57249506
93. Address Street
EVELYN
UNK
Cross Street:
Apt # City State
TN
Zip Code
F
95. Phone No. UNK
MALE WHITE NON HISPANIC OR LATI
100. DOB UNK UNK
0
105. Weight
106. Hair
Brown
107. Eyes
BLUE
108. Scars and Other Identifiers 109. Clothing
YELLOW SHIRT / KHAKI PANTS
NA
Alcohol Drugs Computer
AT LARGE
HANDGUN
(Model)
None Seized (If seized, complete Part 5, Motor Vehicle Section) MVI
(Year) (Make) (Style) (Color) (License No.) (State)
TN
(Yr)
N/A
1
Complainant
MNI NEW
WORTH JOHN
41. Address Street UNK
Cross Street:
Apt No. City State
TN
Zip Code 42. Place of Employment/School
SECRET SERVICE
UNK
PERSON QUESTIONED MALE WHITE
47. DOB UNK UNK HM
WK
Cell/Pager (
N/A
50. Cat CODE Category (Other)
52. Serial No. Owner Applied No. 53. QTY
54. Type CODE 55. Cond CODE Condition CODE (Other)
56. Est $ Value 57. Date Recovered Recovered $Value
58. Stored By CODE Stored By (Other)
Incident Report
M.P.D. Form 100
128.
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1. M.P.D. Incident No.:
2013-0056640
Part 6 Injury
& Transport
85. Injured
86. "Injury" Code (Enter Up to 5)
Part 7 Search By Officer
111. Search Type 112. Searched Location (Address, Area, Etc.)
113.I.D. Section Called To Scene:
Part 8 Other
Units Requested
Yes, for:
114.Other Units Called:
Part 10 Narrative
120.
121. Report is Continued on:
(Check all that apply)
122. Signature of Recipient/Authorizer:
Will Victim Prosecute:
Primary Investigative Unit:
Can Victim/Other Person Identify Suspect(s):
N/A
87. Describe Injury
88. Medical Treatment 89. Transported By
90. Examining Physician
N/A
91. Status
N/A
N/A
Photos Prints Other Other:
THE SUSPECT, , LIVES AT EVELYN AVE OTHER PERSON 1, JOHN WORTH, IS AN AGENT FOR THE SECRET
SERVICE AND IS THE COMPLAINANT. ON THE ABOVE DATE AND TIME, WORTH AND HIS PARTNER WENT TO THE RESIDENCE TO TALK TO
ABOUT A THREAT HE HAD POSTED ON FACEBOOK AGAINST PRESIDENT OBAMA. WORTH STATED THAT WHEN THEY MADE
CONTACT WITH HE ACTED STRANGELY AND SHUT THE DOOR IN WORTH'S FACE. WORTH SAYS THAT CAME BACK TO
THE DOOR WITH SOMETHING DARK IN HIS HAND THAT WORTH AND HIS PARTNER BELIEVED TO BE A GUN. WORTH AND HIS PARTNER FELL
BACK AND CALLED POLICE DISPATCH ASKING FOR ASSISTANCE. WHEN I ARRIVED ON SCENE WITH SEVERAL OTHER OFFICERS, I NOTICED
THE FRONT DOOR TO THE RESIDENCE WAS STANDING OPEN AND MR. WAS WALKING BACK AND FORTH FROM THE FRONT DOOR
BACK INTO A HALLWAY REPEATEDLY. SGT. WARREN SPOKE WITH AGENT WORTH WHO ADVISED THAT THERE WERE NO WARRANTS IN
PLACE AT THE TIME OF INCIDENT AND THEY WERE THERE TO SPEAK WITH ONLY. I ASKED VIA THE PA TO STEP OUT SO
WE COULD SPEAK WITH HIM.
REFUSED AND YELLED ???SHOW ME YOUR WARRANT???. SGT. WARREN ADVISED WORTH THAT WITHOUT A WARRANT THERE
WERE NO FURTHER ACTIONS WE COULD TAKE. OTHER AGENT THEN ASKED SGT. WARREN TO WAIVE A PIECE OF PAPER AT ,
INSINUATING THAT WE HAD A WARRANT. SGT. WARREN REFUSED THAT REQUEST. DOES HAVE A VALID CONCEAL CARRY PERMIT
AND HE WAS INSIDE HIS RESIDENCE. SINCE HAD COMMITTED NO CRIME AND NO WARRANT WAS IN PLACE, WE WERE UNABLE TO
ASSIST THE SECRET SERVICE ANY FURTHER AND ALL OFFICERS LEFT THE SCENE. I DID DO AN FI ON THE SUBJECT AND HAD DISPATCH
FLAG THE ADDRESS.
N/A
Supplement Report Addendum Report
N/A
Refuse to Sign
Victim 1
126. Advisory Notice Issued
N/A
Victim 1 No EAST INVESTIGATIONS
Incident Report
M.P.D. Form 100
128.
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1. M.P.D. Incident No.:
2013-0056640
127. Case Status Cleared by Exception
Person 1 WORTH, JOHN Yes Victim 1 Yes
Reporting Agency:
METROPOLITAN NASHVILLE POLICE DEPARTMENT
Unfounded Cargo Theft
123. Reporting Officer (First, MI, Last)
/S/BENJAMIN MILLER
Employee No.
807340
Agency
TN0190100
Radio Call Sign
235 B
District
124. Approving Supervisor
/S/MATTHEW SEARS
Employee No.
472343
Agency
TN0190100
125. Reviewer
/S/ENISA CERANIC
Employee No.
738248
Agency
TN0190100
Date
01/20/2013
Attachment
Comments
Crime Scene Photo(s) Taken: NO
Incident Report
M.P.D. Form 100
128.
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1. M.P.D. Incident No.:
2013-0056640