Case Support Intake Form

Instructions

The Missing and Murdered Indigenous Relatives office (MMIR office) can provide support, referral and assistance to persons who have a loved one who is missing or has been murdered. Persons seeking such support are asked to complete an intake form with information about their case.

Once the form is completed, a staff member from the MMIR office will contact you within three (3) business days of receiving your request with an update on what kinds of services can be offered. No information will be shared publicly without your consent.

Please fill out this form to the best of your ability with as much information as is available. If you have questions, reach out to the office. Note that for missing persons cases, the MMIR office requires that a police report is filed before we are able to assist. You may reach out to the office directly if you need guidance or help making a report to law enforcement.

The MMIR office is open:

Monday – Friday, 8AM to 4PM, at (651) 201-7344
Requester information
Name*

First nameMiddle nameLast name
She/herHe/himThey/themOther
Relationship to victim or missing person*
YesNo
YesNo
Tribe(s), if enrolled or affiliated
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Phone callEmailText
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Victim or missing person information
Name*

First nameMiddle nameLast name
Aliases or nickname
Date of birth*

MonthDayYear
Date
FemaleMaleTwo spiritTransNon-binaryOther
YesNo
YesNo
Tribe(s), if enrolled or affiliated
Please list any other racial or ethnic identifications
Eye color*
Hair color*
Height*
Weight*
Clothing last worn
Depressed/suicidalExperiencing dementiaExperiencing amnesiaDiagnosed with Alzheimer'sOther
Please list any other unique physical characteristics or identifying marks, such as scars, tattoos, piercings, and birthmarks
Please link any known social media profiles
Currently unshelteredStable housing (lives in one residence)
Last known address (community/neighborhood, city, etc.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Case Information
DeathMissing persons
Date of death/last contact*

MonthDayYear
Date
Location of death/last contact
Law enforcement agency*
Law enforcement agency case number*
NCIC missing person's case number (if known)
Investigator name
Investigator contact
Case status (if known)
Is this person involved with any other systems (for example, child welfare, halfway house, etc.)?
Mental healthSubstance useHuman traffickingDomestic violenceOther
Please describe any known details of the case (for example, if they were travelling in a vehicle, if they were last seen with someone else, etc.). Attach additional files if necessary in the section below.
Questions, needs, or concerns
YesNo
Would you like to add any detail about that experience?
Please indicate questions, needs, or concerns you would like office staff to review. Attach additional files below if necessary.
Additional files

Cancelof
Photo of victim or missing person

Please upload at least one clear photo of the person looking directly at the camera. Avoid any photographs with social media filters. Include images that show any tattoos or identifying marks.
Photo(s)

Cancelof
By checking the box below, consent is hereby granted to the MMIR Office to use the provided photograph(s) of the victim or missing person along with details concerning the disappearance.

The MMIR Office may distribute the photographs and details to local and national media sources, social media, electronic bulletin board systems, Crime Stoppers Minnesota, law enforcement agencies, nonprofit organizations, and other distribution services for the purposes of generating awareness for my loved one’s case.
Yes
Initials

Clear
Acknowledgement and signature
By providing my signature, I certify the following:
- I understand that I must complete all required fields on this form (indicated by a red asterisk *). If I do not, the form will not be submitted to the MMIR office and staff will not contact me.
- All statements and information made by me in this document are true, complete, correct to the best of my knowledge, and are made by me in good faith.
- I understand that the MMIR office is not a law enforcement agency and does not have the authority to respond in-person to crimes or crime scenes, respond to 911 dispatch calls, investigate incidents, re- open closed cases, make arrests, interview persons of interest, or prosecute offenders.
- I understand that any family support services for active cases that the MMIR office provides are completed with the cooperation and collaboration of Tribal and Minnesota criminal justice partners.
- I understand that the information I provide on this intake form and to MMIR office staff directly are classified as private data and will not be shared outside the MMIR office without my permission or if required by court order.
- I understand that by signing this acknowledgement, I give the MMIR office permission to reach out to law enforcement agencies, state or tribal government agencies, or specific organizations or individuals related to this case. I understand that I can revoke that permission at any time, either verbally or in writing. Information I provide will be disclosed only to the extent necessary to assist with my concerns or case.
- I understand that the MMIR office will only communicate with the media about my case with my specific permission.
- This form is valid for one year from the date signed.
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Requester information

Victim or missing person information

Case Information

Questions, needs, or concerns

Photo of victim or missing person

Acknowledgement and signature