Illegal Activity/ Problem Report
Date
-
Month
-
Day
Year
Date
Date and Times of Occurrences:
Location of Activity/ Problem:
Description of Persons:
Police District
4th
Ward
Were Police Called?
YES
NO
If yes, indicate date and time please call:
Date
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Time:
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Your Name (optional):
First Name
Last Name
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Your Address (optional):
Street Address
Street Address Line 2
City
State / Province
Your Phone Number (optional):
Please enter a valid phone number.
You can print and return Form to:
Fourth District Police Department 9333 Kinsman Rd., Cleveland, OH 44104 or call: Commander Brandon Kurtz, (216)623-5405 (fax) 216-623-4594, or: Fourth District Community Relations Board Representative City of Cleveland 601 lakeside Avenue., RM 11, Cleveland, Ohio, 44113. Phone (216)- 664-3578
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