citizens_arrest_formICR # _____________
City of Fridley
Police Department
CERTIFICATE AND DECLARATION OF CITIZEN’S ARREST
Date Of Offense: ____/____/____ Time of Offense: ____:____ am / pm
Location of Offense: _____________________________________________________________________
I, ________________________________ ____/____/____, hereby declare and certify that I have arrested:
Arresting Citizen’s First, Middle, Last Name Date of Birth
Offender: __________________________________________________________ DOB: ____/____/____
Address: ______________________________________________________________________________
For the following crime, ___________________________________________and for the following reason:
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I hereby request and demand that you, a Peace Officer, take custody of this person and deliver or cause
such person to be delivered to a judge of the District Court, to be dealt with according to law. I will present
myself to the appropriate court to give sworn testimony and/or sign any requested formal complaint in
support of the charge(s) for which I have arrested this person. I will hold harmless and agree to indemnify
said officer, the City of Fridley, and it’s Police Department from any and all claim for damage of any kind,
nature, and description arising from their acts at my direction.
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Signature of Citizen Making Arrest Date
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Address City State Zip
Police Officer:______________________________________
Fridley Police Department 6431 University Avenue NE, Fridley, Minnesota 55432 (763) 572-3629