TYPE
OFFENSE/INCIDENT REPORT
INSTRUCTIONS ARE PRINTED SEPARATELY. IF ADDITIONAL SPACE a. ORIGINAL b. CONTINUATION c. SUPPLEMENT
IS NEEDED, USE REVERSE OF FORM; IDENTIFY ITEMS. OR FOLLOWUP
2. CODE NO. 2a. SORT 3. TYPE OF OFFENSE OR INCIDENT 4. CASE CONTROL NUMBER
N/A N/A FRAUD N/A
5. BUILDING NUMBER N/A
N/A
7. NAME OF AGENCY/BUREAU 8. AGENCY/BUREAU CODE 9. SPECIFIC LOCATION 10. LOCATION CODE
CALDWELL COUNTY AD-19 2351 Morganton Blvd SW, Lenoir, NC 28645 RED
SHERIFFS OFFICE
11a. DATE OF OFFENSE/INCIDENT 11a. TIME OF OFFENSE/INCIDENT 12. DAY 13a. DATE REPORTED 13b. TIME REPORTED 14. DAY
MONDAY, June 19, 2017 N/A Monday, June 19, N/A
MONDAY 2017
15. JURISDICTION (X) 16. NO. OF DEMONSTRATORS 17. NO. EVACUATED a. TIME START b. TIME END
EXCLUSIVE CONCURRENT PARTIAL PROPRIETARY 2 N/A
ID CODE NAME AND ADDRESS AGE SEX RACE INJURY CODE TELEPHONE
(a) (b) (c) (d) (e) (f) (g)
Last Name, First, Middle Initial HOME
M E
18. PERSONS
WISE, HUNTER
INVOLVED
a. STATUS
TWENTY DOLLARS WAS TAKEN AND FRAUD WILL BE FILED IF NOT RECOVERED
GENERAL SERVICES ADMINISTRATION GSA FORM 3155 (REV. 3/200)
e. OTHER (Specify)
21. NARRATIVE (If additional space is needed, use blank sheet and attach.)