Reports

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Acknowledgment of Theft Affidavit

Blue Bucket Group, LLC

Name of Agent*

First NameLast Name

Date:*

Time:*

Location:*

Offense/Activity*

Conceal ItemRemove TagSwitch TagArrest

Total Amount of Merchandise Cost:*

Report What Happened:*

Where did this happen in the store?*

Signature of AGENT observing perpetrator shoplifting under New Jersey Statues 2C:20-11 from the Blue Bucket location identified above with the intent to avoid payment. *

Name of Blue Bucket SUPERVISOR as a witness:*

First NameLast Name

Blue Bucket SUPERVISOR fills in how many months is the perpetrator banned from the store*

Signature of Blue Bucket SUPERVISOR: *

Name of PERPETRATOR:*

First NameLast Name

Signature of PERPETRATOR acknowledging and understanding that I have shoplifted under New Jersey Statutes 2C:20-11 merchandise from Blue Bucket Group, LLC with the intent to avoid payment. I further understand that I am prohibited from entering the premises of any Blue Bucket Group, LLC store and failure to comply will likely result in my arrest for criminal trespass.*

Photo of Perpetrator:*

Photo of Perpetrator ID:

Photo of Merchandise:*