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2. If you need immediate assistance, please call the main number at 860-886-5561 Ext. 6. If this is an emergency, please call 911. If you wish to report activity that is on-going and does not require immediate attention, please complete the form below.
   (Warning: Internet IP addresses are captured when submitting this form. Intentionally completing a form with false information can result in a criminal investigation)
6. ****This form is not for a larceny from a retail business or theft of medication. To submit a report of retail theft please choose the option from the previous page. Theft of medication must be reported by calling dispatch.****
8. First Name*
9. Middle Initial
10. Last Name*
11. Suffix
13. Date of Birth*
    Date of Birth
14. Sex*
    -- Select One --MaleFemale
15. Race*
    -- Select One --AsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslandUnknownWhite
16. Ethnicity*
    -- Select One --Hispanic OriginNot of Hispanic OriginUnknown
18. Address*
20. City*
21. State*
22. Zip*
24. Phone Number*
25. Email*
27. Preferred Method of Communication*

    1. Telephone
    2. Email
31. Address of Incident (if different)
33. City
34. State
35. Zip
37. Describe Incident (Provide Item names, values and serial numbers if available)
39. Supporting images or documents:
43. By completing this form, I certify that the information contained herin is true, correct, and complete to the best of my knowledge and belief. I further acknowledge that any intentional false statement or misstatement may be a violation of 53a-180c.
    Please type your name below for the purpose of electronically signing this report (CT Sec. 1-272. Legal recognition of electronic records, electronic signatures and electronic contracts).
45. First and last Name*
46. Date Signed*
    Date Signed
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field