NOTICE OF INQUIRY AND/OR REPORT OF DETAINMENT

NOTICE TO PUBLIC SERVANT / OFFICER: This Questionnaire must be filled-out by Any/

Every public servant Before (s)he can ask the citizen Any question. This is Authorized
by Federal Law including the Privacy Act, 5 U.S.C. 552a, 88 Stat. 1896, et seq., 1974.
In the event you elect NOT to fill this form, you fully Accept and give your Unconditional Consent
for a Levy of your PUBLIC BONDS of no more than $100,000.00 USD (One Hundred Thousand
Lawful Dollars) per each 5 minutes and any portion thereof that I am detained by you and All other
present officers, Notice to Agent is Notice to Principal; Notice to Principal is Notice to Agent!
PUBLIC SERVANT / OFFICER ACCEPTANCE: YES NO (Check One Please)

Name of OFFICER / PUBLIC SERVANT: ______________________________________________

Your BADGE #: __________ JURISDICTION: __________________________________________
Are You A PEACE OFFICER? YES NO (Check One Please)
Are You ON YOUR OATH TODAY? YES NO (Check One Please)
Location of STOP / ARREST _______________________________________________________
______________________________________________________________________________
Do you believe this STOP / ARREST is related to a DRIVER and/or MOTOR VEHICLE Operating
in COMMERCIAL COMMERCE? YES NO (Check One Please)
Please list any PASSENGERS, GOODS, or MERCHANDISE pertaining to the MOTOR VEHICLE:
1. ______________________ 2. _________________________ 3. _________________________
4. ______________________ 5. _________________________ 6. _________________________

***** If you need Additional Space, Please use Back of Form - Check If Back Used  *****
Year: _________ Make: ________________________ Model: _____________________________
License Plate #: _____________________ No Plate? YES NO (Check One Please)
Color: __________________ VIN, ___________________________________________________
Name(s) and Address(s) for each Victim(s) Involved: ____________________________________
Address:_______________________________________________________________________
City: _____________ State: _______________________Phone Number: ____________________

***** If you need Additional Space, Please use Back of Form - Check If Back Used  *****
Is there Property Damage? YES NO (Check One Please) Est. Loss: $ ___________________
Is there Physical Harm? YES NO (Check One Please) Est. Loss: $ _____________________
I, the above BONDED OFFICER do hereby State and Warrant that All information is given under
Oath, is True, Correct, Complete and Not Misleading as stated above under Penalty of Perjury.
Print Name: ______________________ Signature:_____________________ Date: ___/ ___/ 20___

Page 1 of ____ All Terms Herein Defined by Black’s Law 4 th Edition REPORT OF DETAINMENT Ver 003 11-6-20.rtf