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2. Many gas drive-off do not meet the statutory criteria of theft, because there is no intent on the part of the person fueling the vehicle. Gas station employees are encouraged to use this form when there is no evidence the suspect(s) intentionally left without paying for gas. A police officer will contact the gas station within two business days to provide information about how the gas station owner/manager/employee maybe able to contact the owner or driver of the vehicle.

4. Date and Time of Incident*
   Date and Time of Incident

   Date and Time of Incident
5. What was the dollar amount of the loss?*
7. Name of Gas Station*
8. Phone of Gas Station*
10. Street Address of Gas Station*
12. City*
13. State*
14. ZIP*
16. Employee Submitting Report*
17. Phone Number*
18. Email Address
20. Employee Who Witnessed Incident*
21. Phone Number*
22. Email Address
24. Gas Station Owner/Manger*
25. Phone Number*
26. Email Address
28. Is there evidence to believe this was an intentional theft?*

    1. Yes
    2. No
29. Please stop completing this form and call the WPD at (605)882-6210 to report an intentional theft.

    1. This was an intentional theft
    2. No evidence this was intentional
30. Please continue completing this form if there is no evidence to believe this was an intentional theft.

    1. This was an intentional Theft
    2. This was a Mistake
32. Is there video of the incident?*

    1. Yes
    2. No
    3. Unknown
33. Does the video clearly show the vehicle license plate?

    1. Yes
    2. No
    3. Unknown
34. Is someone able to email the video or still pictures to the WPD at a later date?

    1. Yes
    2. No
    3. Unknown
36. Did someone get a description of the vehicle?*

    1. Yes
    2. No
    3. Unknown
38. Make and Model
39. Vehicle Color
40. License No.
41. License State
43. Is the identity of the suspect known to you?*

    1. Yes
    2. No
44. Name of Suspect
45. Any contact info about suspect?
47. Did someone get a description of the suspect(s)?*

    1. Yes
    2. No
48. Was there more than one person with the vehicle?

    1. No, only one person
    2. Yes, two or more people
50. Suspect 1 Sex

    1. Male
    2. Female
    3. Unknown
51. Suspect 1 Hair Color

    1. Black
    2. Brown
    3. Blonde
    4. Gray/White
    5. Red
    6. Unknown
52. Suspect 1 Height

    1. Below 5'0"
    2. 5'0"-5'6"
    3. 5'7-6'0"
    4. Over 6'0"
    5. Unknown
53. Age of Suspect 1

    1. Under 20
    2. 20-30
    3. 30-40
    4. 40-50
    5. 50-60
    6. Over 60
    7. Unknown
55. Suspect 2 Sex

    1. Male
    2. Female
    3. Unknown
56. Suspect 2 Hair Color

    1. Black
    2. Brown
    3. Blonde
    4. Gray/White
    5. Red
    6. Unknown
57. Suspect 2 Height

    1. Below 5'0"
    2. 5'0"-5'6"
    3. 5'7"-6'0"
    4. Over 6'0"
    5. Unknown
58. Age of Suspect 2

    1. Under 20
    2. 20-30
    3. 30-40
    4. 40-50
    5. 50-60
    6. Over 60
    7. Unknown
60. Additional Suspect Info
62. Please use the space below to provide any other details not previously given in the form above*
64. A police officer will contact the gas station within two business days to provide information about how the gas station owner/manager/employee may be able to contact the owner or driver of the vehicle.
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field