WVSP Form 53Revised 11/16
Agency Case No.
Sex Crime Kit Tracking No.
Evidence No. (WVSP Det Use)
Submitting Agency: Date:
Mailing Address: Zip:City:
Investigator: Title:(Last, First, MI)
Time: County of Offense:
Brief Description of Crime:
List Items Submitted: List Section(s) and Examinations(s) Requested:
(use additional sheets if necessary)
1) Victim: DOB:Race: SSN:(Last, First, MI)
2) Victim: SSN:DOB:Race:(Last, First, MI)
DOB:1) Suspect: SSN:(Last, First, MI)
lbs.Sex:Race:SID No: FBI No.
SSN:DOB:2) Suspect:
(Last, First, MI)
lbs.Sex:Race:FBI No.SID No:
FOR LABORATORY PERSONNEL USE ONLY - DO NOT WRITE IN THIS BLOCK
U.S. Mail Certified MailEvidence LockerReceived via:
Other/20Date: /
Request No.Laboratory Case No.
Two copies: Submit with evidence One copy: Retained by submitting officer
-
-
Forensic LaboratoryCase Submission Form
PLEASE TYPE OR PRINT LEGIBLY
Phone #1:Email: Phone #2:
Crime Date:
Criminal Offense:
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