MMBWG Intake Form

Instructions

Please fill out this form to the best of your ability with as much information as possible. If you have questions, reach out to the Office for Missing and Murdered Black Women and Girls (“MMBWG”):

Monday to Friday, 8 a.m. to 4 p.m., at 651-387-1745

A staff member from the MMBWG Office will contact you within three (3) business days of receiving your request.

Please note that for missing persons cases, our office requires that you file a report with law enforcement before to services will be rendered. Reach out to our office if you need guidance or help with making a report to law enforcement.
Requester information
Name

First nameMiddle nameLast name
Preferred pronouns

Other
Relationship to victim or missing person
Phone number
Please enter a valid phone number.Format: 000-000-0000.
Email
example@example.com
Preferred form of communication
Victim or missing person information
Name

First nameMiddle nameLast name
Aliases or nicknames
Date of birth

MonthDayYear
Date
Gender identity

Other
Housing status
HOME (address, community/neighborhood, city, etc.)

Street Address

Street Address Line 2

CityState / Province

Postal / ZIP Code
Case Information
Case type (if known)
Date of death/last contact

MonthDayYear
Date
Location of death/last contact
Investigating agency
Agency case number
Investigator's name
Please indicate questions, needs, or concerns you would like office staff to review (attach additional pages if necessary)
Case status (if known)
Please describe any known details of the case (attach additional pages if necessary)
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
Photo of victim or missing person flyer

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

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

I understand that the MMBWG Office will not engage in interviews or media releases related to information I share. I understand that the MMBWG Office will not release private or sensitive information about my loved one or details of the case if there is concern for the integrity of the investigation.
I accept
Acknowledgement and signature
By providing my signature, I certify the following:
- All statements and information made by me in this document are true, complete, and correct to the best of my knowledge, and they are made by me in good faith.
- I understand that the MMBWG 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 MMBWG Office provides, are completed with the cooperation and collaboration with Minnesota criminal justice partners.
- I understand that the information I provided about this case is considered private under Minnesota State Statute 611A.46 and that access to this collected data is only available to the MMBWG Office, and other statutorily authorized agencies, unless the victim/immediate family or a court authorize its release.
- I understand that I reserve the right to, at any time, revoke this written authorization to the provided private information by informing the MMBWG Office of that fact, with either a written or verbal notice.
Signature
Date

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

Requester information

Victim or missing person information

Case Information

Photo of victim or missing person

Acknowledgement and signature