Graffiti & Damage Notification Form

Incident occurred between:
hours on (last seen undamaged) AND
hours on (damage discovered)

Incident Location :

(Include business/trading name if applicable, ie Kmart Ltd trading as Kmart Mandurah)

Describe the damage/graffiti sighted (if you are able to distinguish words within the graffiti, please specify):

What property is damaged &/or vandalised? (ie street sign, shop wall, pathway etc)

Who owns this piece of property? Is it public or private property?
Name:
Address:
Telephone:
Date of Birth:
Day: Month: Year:

If known, who is responsible for the damage/vandalism?

  1. Name:
    Address:
    Telephone:
    Other details known about this person:
  2. Name:
    Address:
    Telephone:
    Other details known about this person:

Any Witnesses, who can identify the Person of interest?
Name:
Address:
Telephone:
Date of Birth:
Day: Month: Year:
Place of Employment:

Date and time the damage was repaired/removed:

Approximate cost of damage/removal expenses:

Details of the person completing this form.
Name:
Address:
Telephone:
Date of Birth:
Day: Month: Year:

Last modified 04-Apr-2007 01:38 PM