NOTICE OF INQUIRY AND/OR REPORT OF DETAINMENT This questionnaire must be filled-out by any public servant before he can ask the citizen any ‘question. This is authorized by federal law, including the Privacy Act, § U.S.C. §52a, 88 Stat. 1896, et seq., 1974, Name of OFFICER / PUBLIC SERVANT. BADGE #, JURISDICTION, PEACE OFFICER YES * NO (circle one please) ON YOUR OATH TODAY? YES * NO LOCATION OF STOP / ARREST. Do you believe that this STOP is related to a DRIVER or MOTOR VEHICLE operating in commercial commerce? YES * NO (circle one please) Please list any PASSENGERS, GOODS, or MERCHANDISE attached to or inside the above said MOTOR VEHICLE: Fs 2 3. 4, 5, 6. ‘**4****if you need additional space please use the back******* Year Make Model License Plate No Plate? YES * NO (circle one please) Color: VIN, Victim(s) involved Address Phone Number. *** f you need additional space please use the back* Property Damage? YES * NO (circle one please) $ est. loss Physical Harm? YES * NO (circle one please) $, est. loss | as the above states BONDED OFFICER state that all information is given under oath, and is true and correct as stated above under penalty of perjury. Print Name Signature Date NOTICE TO PUBLIC SERVANT / OFFICER In the event you elect to not fill this form, you will accept or give your unconditional consent for a levy of your PUBLIC BONDS of no more than $100,000.00 USD (one hundred thousand daltars) per 5 minutes that | am detained by you or ALL other present officers. NOTICE TO AGENT IS NOTICE TO PRINCIPAL; NOTICE TO PRINCIPAL IS NOTICE TO AGENT PUBLIC SERVANT / OFFICER REFUSAL: YES * NO (circle one please)