Non-Consent Form

2. LDPD Case #
3. Officer's Name
5. Business Name (if applicable)
7. Name*
8. Birthdate*
10. Address
12. City
13. State
14. Zip Code
16. Phone Number*
17. Email Address
19. Involvement*

    I am the (check all that apply)

    1. Victim
    2. Lessee

    1. Owner or Co-owner
    2. Manager

    1. Employee
    2. Officer of Corp. or Assoc.

    1. Other
21. Describe victimized property, building, vehicle, etc.
23. Suspect's name, if known
25. I did not give consent to anyone, including the person listed above, to:*

    1. Cause bodily harm to me
    2. Threaten or harass me
    3. Damage or destroy my property

    1. Sexually assault me
    2. Take possession of my property

    1. Enter my property
    2. Other
27. If other, please explain
29. Date and time of incident*
    Date and time of incident

    Date and time of incident
30. Location of incident*
32. Date and time*
    Date and time

    Date and time
33. Electronic Signature*
35. Date and time
    Date and time

    Date and time
36. Officer's Signature
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field