Your details

PLEASE NOTE : This service relates to road safety offences only. It is NOT for submitting footage of Road Traffic Collisions or public order offences, any reports of parking offences should be referred to the relevant highway authority in the locality where it occurred. If you wish to report another matter please refer to the West Yorkshire Police website for guidance. In emergency situations please call 999.

Please note that, if you operate a recording device in a public place, you may have obligations under the General Data Protection Regulation (GDPR). It is in your interest to familiarise yourself, and comply with, any such obligations as apply to you. If you are in any doubt as to your obligations, please obtain independent legal advice to ensure you do not put yourself at risk of prosecution. Please tick this box to acknowledge you have read and understood the above notice before proceeding

First name

Last name

Address line 1

Address line 2

Town/City

County

Post Code (no white space)

Email address

Mobile telephone number

Home telephone number

Work telephone number

Preferred means of contact

Date of birth

Statement

PLEASE NOTE : This service relates to road safety offences only. It is NOT for submitting footage of Road Traffic Collisions or public order offences, any reports of parking offences should be referred to the relevant highway authority in the locality where it occurred. If you wish to report another matter please refer to the West Yorkshire Police website for guidance. In emergency situations please call 999.

I confirm this statement is true to the best of my knowledge and belief and I make it knowing that if it is tendered in evidence I shall be liable to prosecution if I have wilfully stated in it anything which I know to be false, or do not believe to be true.

Signed

Date

Location of incident – INCLUDING Road Name/number and Town/City

County of incident

Date of incident

Time of incident

Do you know the offender?

Yes No

Do you know the make and model of the offending vehicle?

Yes No

Make of offending vehicle (if known)

Model of offending vehicle (if known)

Registration of offending vehicle (no white space) - this must be clearly visible on the footage

Colour of offending vehicle

You are the

Make of your vehicle

Model of your vehicle

Registration of your vehicle

Colour of your vehicle

Details of the vehicle you were the passenger in

Make of your bicycle

Model of your bicycle

Color of your bicycle

Clothing worn

Age of the horse

Size of the horse

Colour of the horse

Clothing worn

Where were you located in relation to the offender

Where was the offending vehicle in relation to you when the offence took place?

In your own words, describe what happened including as much detail as possible

About device used to record the footage

How is the device fitted/secured?

How does your device record and/or store footage?

By making a report, you understand that you may be required to attend court in order to confirm the information given in your statement. The police will be able to support you through this process. Please note that not all cases will be heard in court. Please confirm you understand and are willing to attend court

I am willing to attend Court and give evidence in relation to this matter.

All statements associated with an offence or prosecution will be retained in line with the police forces retention policies.

I am happy for this statement and digital imagery/footage to be disclosed as part of the Criminal Justice process and for casualty prevention purposes.

Signed

Date

Equality information

In order to improve our service and to ensure that everyone has an equal opportunity to benefit from the facilities we offer, it would help if you could answer the below questions. These questions are optional and will not affect your submission. You can find out how your personal information will be used in the our Privacy Information Notice on our website.

Sex:

Other sex details

Is your gender the one you were assigned at birth?

Other gender details:

Other gender details

Sexual orientation:

Other sexual orientation details

Do you have a physical or mental impairment that has a substantially adverse and long-term effect on your ability to carry out normal day-to-day activities?

Which option below describes your disability? (tick all that apply)

Hearing

Learning difficulty

Long standing illness or health condition

Mental health condition

Mobility or physical impairment

Sight

Not known

Prefer not to say

Other (please give details)

Other disability details

Ethnicity:

Please describe

Religious belief/faith:

Other religion details

Upload your supporting files

DO NOT alter the footage before uploading, this includes adding voice overs or adding inline comments.

Footage uploaded MUST be raw original footage, with NO EDITING of any kind. The footage should include the whole incident and wherever possible, should include 1 minute prior and 1 minute after the commission of the offence. The footage should not be any longer than 10 minutes in duration.

DO NOT post the footage on social media – if you have done so, please remove it.

DO NOT delete the footage from your device.

Please be aware that your device may have recorded you and that the actions of all parties will be reviewed and action taken as appropriate.

File Upload

Is the date/time displayed on the footage the same as the time at which you stated the incident happened above?

Yes No

Please explain in the box below why there is a difference in the time stated above on your statement and the timestamp on your video. This information is required for evidence continuity purposes

Verification

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Your details

Statement

Equality information

Upload your supporting files

Verification