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:

109

8

7

1

2

3

4

5

6

_____________________________________________________

_________________________________________

______________________________________

________________________________________________________________________________________________________________________ _____________________________

___________________________________________________________________________________ ____________________________________________ _________________

____________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________ ________________________________________________

______________________________________________________________________ ______________________________________ _____________________________________

________________________________________________________________________________________________________________________________________________________________

____________________________ ______________________ _______________________________________________________

__________________________

__________________________

__________________________

__________________________

_________ ___________

_________ __________

_________ __________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

- -

________________________________________________________________

________________________________________________________________

________________________________________________________________________________

_________

_________

_____

________

______

_____________ _____________ ______________________________________ _______ ft. _______ ________

______________________________________ _______ ________

________________________________________________________________________________

_____________ _____________

_________ ______ __________

in. Wt:

in. Wt:

Ht:

Ht: ft.

___________

__________ ____________

____________

__________