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2. Name of Store*
3. Address of Store*
5. Phone Number of Store*
6. Name of Person Making Complaint*
8. Title of Person Making Complaint*
9. Date of Theft*
   Date of Theft
11. Time of Theft*
12. Value of Theft*

    1. Under $500
    2. $500 to $1,000
    3. $1,000 to $5,000
    4. Over $5,000
14. Do you have ability to email WPD statement form*

    1. Yes
    2. No
15. Do you have photos of suspects?*

    1. Yes
    2. No
17. If you have suspect information, please provide it here
19. All other information here
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field