Incident Report | Department of Transportation

Incident Date

Name of Individual Being Reported (first, middle, last, suffix)

Driver License Number

Phone (Individual Reported)

Residential Address

City

State

Zip

Incident Location/Address

City

State

Zip

VIN (if applicable)

Make

Model

Year

Plate

Name of Dealership Being Reported (if applicable)

Dealership Address

Incident Description

Describe in full detail who all was involved (employees and/or witnesses), what took place, actions taken, and if applicable list all outside agencies contacted (e.g. police department, contact information of person spoken to, case number, etc).

Attachments

Describe all documents attached (DL/ID, Title work, Police report, etc).

Individual Reporting the Incident

Name (first, middle, last, suffix)

Driver License Number

Phone

Residential Address

City

State

Zip

Email Address

I wish to remain anonymous and understand I may be contacted for further information.

Yes

Certification

By signing/ typing your name and submitting the form, I certify under penalty of perjury, that the information stated above is true and correct to the best of my knowledge.

Signature

Date

File attachments

Unlimited number of files can be uploaded to this field.
2 MB limit.
Allowed types: jpg, jpeg, pdf.