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Driver Information Exchange INVESTIGATING AGENCY ILLINOIS STATE POLICE COUNTY SANGAMON OFFICER S NAME / ID Joe J. Officer / 145 CITY OR TOWNSHIP CHATHAM TWP AGENCY RPT NO. 09-04-00000 MCR ID ISP-145-20040526-154159 CRASH LOCATION ADDRESS State Route 4 NB 0. 69 Mi. - S ALPHA RD DRIVER S NAME Last First M. I. DRIVER S PHONE YEAR MAKE MODEL SIMPSON HOMER J 217 555-1212 1995 FORD GRANADA DRIVER S ADDRESS Street City State Zip Unit 1 CRASH DATE 05/26/2004 PLATE NO. / STATE 23 EVERGREEN TERRACE SPRINGFIELD IL 62701 XLL 4378 / IL DRIVER S LICENSE NO. S555-1234-1234 VEHICLE OWNER S NAME Last First M. I. Abstainers Insurance Company H73773888S8 Please use the information for your unit number above to assist you in completing your Illinois Motorist report. Retain this form for your records. Copies of IL Crash Reports may be obtained by sending a check or money order for 5 per copy made payable to Illinois State Police Attn Crash Report Unit 500 Iles Park Place Springfield IL 62703-2982 or go to www. Illinoisepay. com LEGAL REQUIREMENTS The Driver of any motor vehicle involved in a crash which results in injury death or damage to any one person s property in excess of 500 must complete an Illinois Motorist Report and submit it to the Illinois Department of Transportation within 10 days after the date of crash. If the driver is physically incapable of completing the report the vehicle owner or another occupant of the vehicle should do so. 09-04-00000 MCR ID ISP-145-20040526-154159 CRASH LOCATION ADDRESS State Route 4 NB 0. 69 Mi. - S ALPHA RD DRIVER S NAME Last First M. I. DRIVER S PHONE YEAR MAKE MODEL SIMPSON HOMER J 217 555-1212 1995 FORD GRANADA DRIVER S ADDRESS Street City State Zip Unit 1 CRASH DATE 05/26/2004 PLATE NO. I. DRIVER S PHONE YEAR MAKE MODEL SIMPSON HOMER J 217 555-1212 1995 FORD GRANADA DRIVER S ADDRESS Street City State Zip Unit 1 CRASH DATE 05/26/2004 PLATE NO. / STATE 23 EVERGREEN TERRACE SPRINGFIELD IL 62701 XLL 4378 / IL DRIVER S LICENSE NO. S555-1234-1234 VEHICLE OWNER S NAME Last First M. / STATE 23 EVERGREEN TERRACE SPRINGFIELD IL 62701 XLL 4378 / IL DRIVER S LICENSE NO. S555-1234-1234 VEHICLE OWNER S NAME Last First M. I. Abstainers Insurance Company H73773888S8 Please use the information for your unit number above to assist you in completing your Illinois Motorist report. I. Abstainers Insurance Company H73773888S8 Please use the information for your unit number above to assist you in completing your Illinois Motorist report. Retain this form for your records. Copies of IL Crash Reports may be obtained by sending a check or money order for 5 per copy made payable to Illinois State Police Attn Crash Report Unit 500 Iles Park Place Springfield IL 62703-2982 or go to www. Retain this form for your records. Copies of IL Crash Reports may be obtained by sending a check or money order for 5 per copy made payable to Illinois State Police Attn Crash Report Unit 500 Iles Park Place Springfield IL 62703-2982 or go to www. Illinoisepay. com LEGAL REQUIREMENTS The Driver of any motor vehicle involved in a crash which results in injury death or damage to any one person s property in excess of 500 must complete an Illinois Motorist Report and submit it to the Illinois Department of Transportation within 10 days after the date of crash.

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