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2. Important Notice
   Arkansas Code 5-54-122: Filing false report with a law enforcement agency. Report means any communication, either written or oral, sworn or unsworn.
4. Offense*
   -- Select One --Criminal MischiefCriminal TrespassHarassmentIdentity Theft / ForgeryShopliftingTheft of PropertyTheft of Motor FuelUnsightly ConditionsInterference with Child CustodyLeaving Scene of AccidentOther

   This is a Required Field. Please Choose an offense. For details see Offense Descriptions.
5. Offense Descriptions
   View offense documents.
7. Date / Time the Offense Occurred*
   Date / Time the Offense Occurred

   Date / Time the Offense Occurred
   Required
8. Address / Location Where the Offense Occurred*
   Address / Location must be within the City Limits of Blytheville AR.
12. Your Name*
    Required
13. Your Address*
    Required
15. City*
    Required
16. State*
    Required
17. Zip
19. Your Date of Birth*
    Your Date of Birth
    Required
20. Race*
    -- Select One --WhiteBlackAsianNative AmericanNative Pacific Islander

    Required
21. Gender*
    -- Select One --MaleFemale

    Required
22. Ethnicity*
    -- Select One --YesNo

    Hispanic
24. Your E-Mail Address
25. Your Phone Number
27. Business Name (If Involved)
28. Business Location
32. Witness / Suspect
    -- Select One --WitnessSuspectOffender
34. Name
    If Known
35. Address
37. Date of Birth
    Date of Birth
    If Known
38. Gender
    -- Select One --MaleFemale

    If Known
39. Race
    -- Select One --WhiteBlackAsianPacific Islander

    If Known
40. Phone Number
    If Known
42. Witness / Suspect
    -- Select One --WitnessSuspectOffender
44. Name
45. Address
47. Date of Birth
    Date of Birth
    If Known
48. Gender
    -- Select One --MaleFemale

    If Known
49. Race
    -- Select One --WhiteBlackAsianPacific Islander

    If Known
50. Phone Number
54. Property
    -- Select One --DamagedStolen
55. Property Description
56. Serial Number
57. Value
59. Property
    -- Select One --DamagedStolen
60. Property Description
61. Serial Number
62. Value
64. Upload Supporting Information
    You can Upload supporting documents or photos.
66. Narrative*
    Required
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field