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[FBI NIBRS Based Form]

SUPPLEMENTARY HOMICIDE REPORT
This report is authorized by law Title 28, Section 534, United States Code. Your cooperation in using this form to list data pertaining to all homicides reported on your
Return A will assist the FBI in compiling comprehensive, accurate data regarding this important classification on a timely basis. Within 30 days of the homicide
incident, the chief law enforcement officer for an agency must submit a completed form to the Minnesota Bureau of Criminal Apprehension.

Submit Report Online at: https://mnjis.x.state.mn.us

Send Questions to: [email protected]

REPORT ONLY ONE INCIDENT PER FORM- Report all homicides for this incident (case#) on this form.
*Agency ORI:

*Agency Name:

*Date of Incident: (mm/dd/yyyy)
Yes

*Incident/Case Number:

(8 characters)

No The date given above is the actual incident date of the Homicide, and not the date the incident was reported.

Yes

*Was there a death in this incident?

No

Do any of the