Police Report Withdrawal Request Form
Submit your request to withdraw an existing police report complaint. Please provide accurate information to help us process your request efficiently.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Report Number
*
Date Report Was Filed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Police Station or Department Name
*
Type of Incident Reported
*
Please Select
Theft
Assault
Fraud
Vandalism
Other
Reason for Withdrawal
*
Relationship to the Original Complaint
*
Please Select
Complainant
Legal Guardian
Attorney
Other Representative
Declaration: I confirm that I am authorized to request the withdrawal of this police report and that the information provided is accurate to the best of my knowledge.
*
I agree and authorize the withdrawal request
Submit Withdrawal Request
Should be Empty: