If you witness a
crime, it is your civic duty to report the crime to the police.
When a crime is committed,
you have the right and responsibility to make a
Thus, if YOU commit
a crime, it would be extremely helpful (and provide a
savings of tax dollars) for you to perform a
Fill out the handy form, below,
to complete your Citizen's Self-Arrest:
Fill out this form, answering all questions completely.
Top of Form
Enter your full name:
Nickname or ALIAS:
Enter your home street address:
Home Phone #:
Identifying Scars/Tattoos, if
for which you are arresting yourself:
If Other, specify:
Bottom of Form
the following statement aloud:
under arrest. I have a right to remain silent. Anything I say can
and will be used against me in a court of law. I have the right to
talk to a lawyer and have him/her present with me while I question
myself. If I cannot afford to hire a lawyer, one will be appointed
to represent me, if I wish one, before I question myself. If I
decide to make a statement, I may stop at any time."
understand each of these rights I have just read to myself? Yes
Having these rights in mind, do I wish to talk to myself
(If YES to both, use the space below for your full
or other statement you may wish to make.)
Memorize the following rules:
not leave your house. If you are not home now, go
any firearms or other potential weapons out of
Remove your belt and shoelaces.
others are present in your house, send them away.
You may, however, talk to yourself.
are not to allow yourself any visitors.
Conjugal visits are not permitted.
Consumption of alcohol or use of any other
non-prescription drugs is not permitted.
not try to escape from your home.
you do attempt an escape, use all reasonable force
to stop yourself.
Report any escape attempts promptly, by phone, to
the local police.
not disturb any evidence present in your home.
Remain in your home until the police arrive.
To ensure your
Citizen's Self-Arrest is received, mail a copy of this form to your
local police department, in accordance with the following
stamp-pad or ink-soaked sponge/tissue, provide a preliminary set
of fingerprints on the printed copy of the form:
you have a recent passport-size photograph, enclose it with this
If you do not have a photo, but do possess some artistic
skill, do a rough sketch of your appearance on a separate sheet
(Do NOT sketch yourself wearing dark glasses;
do not add a beard or mustache if you do not
normally have one.)
If you do
not have a printer, type or carefully draw a facsimile of
this form on a blank piece of paper and fill in the appropriate
Submission of a neat and complete form will be
pointed out favorably to the DA's office.
(required for mail-arrests only)
date the copy of this form you've printed and mail it to your
local police department. If you do not know the address of your
local department, send it to this address:
City of Burbank Police
5650 W. 75th PL Burbank IL 60459
Attention: Arrest-by-Mail Program.
You are authorized to make one trip to a mailbox for this
If you live outside the B.B.P.D jurisdiction we will fax it to your
local police department.