LAPORAN POLISI

DI MANA:
Kota_____________ Lingkungan _________ Zona ____________
Subzona__________________
Jalan ______________________________ Nomor Eksterior________ Nomor Interior_______
Deskripsi tempat
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KAPAN:
PENANGKAPAN ATAU PENAHANAN Tahun ________ Bulan ________ Hari _________
Jam _________
KEJAHATAN ATAU PELANGGARAN: Tahun ________ Bulan ________ Hari _________
Jam _________

ITU:
Jenis layanan: _________________________________________________________________
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SIAPA:
DIHENTIKAN ATAU DITANGKAP:
NAMA _________________________________________________________________
ALAMAT: Jalan __________________________________________ Nomor
Eksterior____________ Nomor Interior______________, Usia __________, Jenis Kelamin
____________, Tinggi Badan _________ Kulit _________ Warna Kulit ________ Jenis Rambut
________, Mata ________, Mulut __________, Telinga _________, Hidung __________,
Karakteristik atau detail pribadi (tato, cacat asi, tindikan , anting-anting, cara berdiri, berjalan)
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Jenis Pakaian (jenis, warna, bentuk, pakaian, alas kaki dan asesorisnya, seperti anting, gelang,
dll): _________________________________________________________________________
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KORBAN:
NAMA _________________________________________________________________
ALAMAT: Jalan __________________________________________ Nomor
Eksterior____________ Nomor Interior______________, Usia __________, Jenis Kelamin
____________, Tinggi Badan _________ Kulit _________ Warna Kulit ________ Jenis Rambut
________, Mata ________, Mulut __________, Telinga _________, Hidung __________,
Karakteristik atau detail pribadi (tato, cacat asi, tindikan , anting-anting, cara berdiri, berjalan)
_________________
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Jenis Pakaian (jenis, warna, bentuk, pakaian, alas kaki dan asesorisnya, seperti anting, gelang,
dll): _________________________________________________________________________
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SAKSI:
NAMA _______________________________________________________________
ALAMAT: Jl. ____________________________________________________________ No.
Ext. _________ TIDAK. Int. ______________, Usia __________, Jenis Kelamin ____________
Deskripsi ___________________________________________________________
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NAMA _______________________________________________________________
ALAMAT: Jl. ____________________________________________________________ No.
Ext. _________ TIDAK. Int. ______________, Usia __________, Jenis Kelamin ____________
Deskripsi ___________________________________________________________
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SEBAGAI:
MENCARI FAKTA: _________________________________________
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MENGAPA: (Mereka melihat fakta, mereka meminta layanan kewarganegaraan, laporan kabin)
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UMUM:
Objek yang diasuransikan:
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Otoritas lain campur tangan:
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Pesanan atau indikasi khusus diterima:
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Fakta yang tidak disengaja atau umum, seperti terluka, terancam, berpengaruh,
direkomendasikan:
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AGEN __________________________________________________
DERAJAT _____________________________________
SATUAN ____________________________________

TANDA TANGAN______________________________________
KORBAN______________________________ TANDA
TANGAN__________________________
TERIDENTIFIKASI
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TANDA TANGAN SAKSI__________________________

TERIDENTIFIKASI
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TANDA TANGAN SAKSI__________________________

TERIDENTIFIKASI
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