CITATION FOR VIOLATIONS OF GOD-GIVEN RIGHTS Location of Occurance:______________________________________________________________ Date and Time:______________________________________________________________________ Name of Person stopped and detained: 1)_______________________________________________________________________ Sex: M - F Location/Address:________________________________________________ Arrested: Yes - No Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ 2)_______________________________________________________________________ Sex: M - F Location/Address:________________________________________________ Arrested: Yes - No Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ 3)_______________________________________________________________________ Sex: M - F Location/Address:________________________________________________ Arrested: Yes - No Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ 4)_______________________________________________________________________ Sex: M - F Location/Address:________________________________________________ Arrested: Yes - No Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ Name of Officer(s) that made the stop: 1)_______________________________________________________________________ Sex: M - F Ht______ Wt______ Race______ Etc.___________________________________________________ Badge #____________________ ID#____________________ Driver's Lic#___________________ Location/Address:___________________________________________________________________ Police Agency:_______________________________________ Maranda Warning Read: Yes - No Supervisor:_______________________ Office mailing address___________________________ Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ 2)_______________________________________________________________________ Sex: M - F Ht______ Wt______ Race______ Etc.___________________________________________________ Badge #____________________ ID#____________________ Driver's Lic#___________________ Location/Address:___________________________________________________________________ Police Agency:_______________________________________ Maranda Warning Read: Yes - No Supervisor:_______________________ Office mailing address___________________________ Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ 3)_______________________________________________________________________ Sex: M - F Ht______ Wt______ Race______ Etc.___________________________________________________ Badge #____________________ ID#____________________ Driver's Lic#___________________ Location/Address:___________________________________________________________________ Police Agency:_______________________________________ Maranda Warning Read: Yes - No Supervisor:_______________________ Office mailing address___________________________ Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ Name of Back-up Officer(s): 1)_______________________________________________________________________ Sex: M - F Ht______ Wt______ Race______ Etc.___________________________________________________ Badge #____________________ ID#____________________ Driver's Lic#___________________ Location/Address:___________________________________________________________________ Police Agency:_______________________________________ Maranda Warning Read: Yes - No Supervisor:_______________________ Office mailing address___________________________ Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ 2)_______________________________________________________________________ Sex: M - F Ht______ Wt______ Race______ Etc.___________________________________________________ Badge #____________________ ID#____________________ Driver's Lic#___________________ Location/Address:___________________________________________________________________ Police Agency:_______________________________________ Maranda Warning Read: Yes - No Supervisor:_______________________ Office mailing address___________________________ Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ 3)_______________________________________________________________________ Sex: M - F Ht______ Wt______ Race______ Etc.___________________________________________________ Badge #____________________ ID#____________________ Driver's Lic#___________________ Location/Address:___________________________________________________________________ Police Agency:_______________________________________ Maranda Warning Read: Yes - No Supervisor:_______________________ Office mailing address___________________________ Conveyance Description:Yr______Make___________ Model______________ Tag # ___________ List of Items obtained by Officer(s) from party stopped:____________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ If citation issued, Citation Number(s):_____________________________________________ Name, Location/Address & Phone # of other persons on scene:_________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Probable Cause for stop as stated by Officer:_______________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Law or regulation authorizing investigation or questions as stated by Officer:______ ____________________________________________________________________________________ Is this agency using any information pertaining to me which was supplied by another agency or government source? Yes _____ No ____ If yes, which agencies and/or sources? _____________________________________________ May I have a copy of that information? __________ Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the information which you seek? Yes___ No___ Was the incident tape recorded? Yes - No By whom:___________________________________ Detailed Observation of incident:___________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Date Report Made: __________________________ Time Report Made:______________________ Printed Name of Reporting Person:___________________________________________________ Signature of Reporting Person:______________________________________________________