LE 022 (08-16-2019)
Purpose: Use this form to report incidents requiring DMV Law Enforcement attention, such as suspicious activity related to motor
vehicles, driver licensing, fuels taxes, motor vehicle dealer transactions, DMV transactions, or property/passenger carrier
operations.
Instructions: All fields are not required but please complete as much information as possible. This will assist in the investigation of
your complaint. If you are completing the form by hand and the space provided is not sufficient, please feel free to write
on the back of the form or attach an extra page.
To submit completed form: (1) Save it electronically and email to enforcement@dmv.virginia.gov; (2) mail it to the
address shown above or (3) send printed form via fax to (804) 367-8087. If you have questions, please call (804)
367-1678 or (804) 367-1997.
NOTE: ● All complaints are reviewed by DMV law enforcement. Some investigations are complex and can take several weeks
or months to resolve.
● Falsely reporting a crime is unlawful and punishable as a misdemeanor (VA Code §18.2-461).
GENERAL COMPLAINT
REPORTING INDIVIDUAL INFORMATION
STREET ADDRESS CITY/TOWN ZIP CODE
MAY A DMV LAW ENFORCEMENT AGENT CONTACT YOU?
YES NO (Checking no may impede a successful investigation of your complaint.)
HOW DO YOU WANT TO BE CONTACTED?
NAME (first, middle, last)
STATE
ALTERNATE TELEPHONE NUMBER PRIMARY TELEPHONE NUMBER
EMAIL ADDRESS
EITHERPHONE EMAIL
IF CRIMINAL CHARGES ARE WARRANTED, ARE YOU WILLING TO COOPERATE AND BE A WITNESS FOR COURT APPEARANCES?
YES NO
VICTIM INFORMATION (If other than reporting individual)
NAME (first, middle, last)
STREET ADDRESS
EMAIL ADDRESS
CITY/TOWN STATE ZIP CODE
TELEPHONE NUMBER
VEHICLE INFORMATION (if applicable)
VEHICLE YEAR
VEHICLE MAKE VEHICLE MODEL
VEHICLE
COLOR
PRIMARY SECONDARY
STATE OF ISSUE MILEAGE
VEHICLE IDENTIFICATION NUMBER (VIN)
PURCHASE DATE (mm/dd/yyyy}PLATE NUMBER
INCIDENT DETAIL INFORMATION
STREET ADDRESS CITY/TOWN ZIP CODE
SUSPECT/OFFENDER NAME (Business name or first, middle, last of individual)
TELEPHONE NUMBER
STATE
HAS THE INCIDENT BEEN REPORTED TO ANY OTHER LAW ENFORCEMENT AGENCY?
IF YES, WHICH AGENCY?
YES NO
SUSPECT/OFFENDER INFORMATION
STREET ADDRESS CITY/TOWN ZIP CODE
BUSINES NAME/TRADE NAME/DMV OFFICE/OTHER LOCATION WHERE THE INCIDENT OCCURRED
STATE
INCIDENT LOCATION (enter as much information as possible)
INCIDENT DATE (mm/dd/yyyy) and TIME
