UW-EAU CLAIRE POLICE _
__
_____
105 Garfield Avenue, PO Box 4004 CWC119
Eau Claire, WI 54701
(715) 836-2222
Loss/Damages Form
CASE # ______________
DATE
In order that the court may have a full account of the loss/damage you recently experienced due to unlawful conduct, we ask that you
give a detailed outline of the total amount of such loss/damage.
If applicable, provide a copy of any bill or service charge incurred due to damages as a result of an unlawful act. If an item has been
lost or stolen, please provide a receipt for that item, if possible.
Description of item
Est. Value
If any of the items above are covered under an insurance policy please include the name of the insurance company and the
insured below.
Insured by:
Policy Holder:
As evidenced by my signature below, I did not give anyone permission to remove/damage the items listed above. The
above statement of loss/damages is true and correct to the best of my knowledge.
Signature: ________________________________________________
Date: _____/_____/_____ Time: __________ AM/PM
Witness: _________________________________________________
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