State of New Jersey

Department of Transportation

Office of Inspector General

Loss, Theft, and Vandalism Report

Person Completing Loss, Theft, and Vandalism Report

First Name

Last Name

Title

Business Telephone

State of New Jersey

Department of Transportation

Office of Inspector General

Loss, Theft, and Vandalism Report

Information Concerning the Loss, Theft or Vandalism

Date of loss, theft or vandalism

Location where loss, theft or vandalism occurred, including region

How did you learn of the loss, theft or vandalism? (Describe your findings)

Did anyone witness the theft or vandalism?

Yes

Please complete the section below:

First Name (witness)

Last Name (witness)

Street Address

City

State Value is not selected

Zip

Phone Number (witness)

Email Address (witness)

State of New Jersey

Department of Transportation

Office of Inspector General

Loss, Theft, and Vandalism Report

Police Investigation

Did you notify police?

Yes

Police Department

State

Local

Date Police notified

Time Police notified (if applicable)

Report Number

First Name (Police officer)

Last Name (Police officer)

Street Address (Police department)

City (Police department)

State (Police department) Value is not selected

Zip (Police department)

Phone Number (Police department)

State of New Jersey

Department of Transportation

Office of Inspector General

Loss, Theft, and Vandalism Report

Signature (Person completing this Report)

Email Address (Person completing this Report)

Confirm Email Address (Person completing this Report) *

I certify that my statements in this report are accurate.

Signature (Person completing this Report)

Signature Date (Person completing this Report)

Submit will forward this report to the Office of the Inspector General for processing.

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IG - 0004A - Loss, Theft, and Vandalism Report (IG-99)