POLICE INCIDENT REPORT FORM

Use this form to report accidents, injuries, medical situations, criminal activities, traffic
incidents, or student behavior incidents. If possible, a report should be completed within
24 hours of the event.

Date of Report: 03/27/2023

1. PERSON INVOLVED

Full Name: Fernando Mejia Address: 13809 Bauer Dr, Rockville, MD, 20853

Identification: ☐ Driver’s License Number ☐ IdentificationNumber

No. 4850055

Phone: 202-534-5221 E-Mail: fernandomejia001@gmail.com

2. THE INCIDENT

Date of Incident: 03/24/2023 Time: 08:00 ☐ AM ☐ PM

Location: eBay.com // Rockville, Maryland, 20853.

Describe the Incident: Online Fraudulent Activity involving an iPhone 13 Green Color

3. INJURIES

Was anyone injured? ☐ Yes ☐ No

If yes, describe the injuries:

4. WITNESSES

Were there witnesses to the incident? ☐ Yes ☐ No

If yes, enter the witnesses’ names and contact info: Fernando Mejia // 202-534-5221

5. POLICE / MEDICAL SERVICES

Police Notified? ☐ Yes ☐ No

If yes, was a report filed? ☐ Yes ☐ No
Was medical treatment provided? ☐ Yes ☐ No ☐ Refused

If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other:

REFERENCE NUMBER RM 27541976

 6. PERSON FILING REPORT

Signature: ________________________ Date: __03/27/2023

Print Name: ___Fernando Mejia___________

OFFICE USE ONLY

Report received by: Officer John Gloss Date: 03/27/2023

Badge #: GLOSS 5653

Action Taken: Filed for Investigation.

2 W. Montgomery Ave.
Rockville, MD 20850
240-324-8900 Monday - Friday
Emergency: 9-1-1 8:30 a.m. - 5:00 p.m.
E-mail: publicsafety@rockvilllemd.gov

REFERENCE NUMBER RM 27541976