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              สวนราชการ  สถานีตํารวจ/หนวยงาน...............................กก. ................................บก. ......................
              ที่............................................................วันที่.................เดือน...............................พ.ศ. ................
              เรียน..................................................................................................................................................
                            บัญชีทรัพยถูกประทุษรายหรือหาย
              สิ่งที่สงมาดวย.................................................................................................................................
              ÃÒÂÅÐàÍÕ´¡ÒÃËÒ                             เกี่ยวกับคดี                    ไมเกี่ยวกับคดี
              ผูเสียหาย.........................................................................................................................................

              ที่อยู...............................................................................................................................................
              ผูแจงหาย........................................................................................................................................
              ที่อยู...............................................................................................................................................
              ฐาน/เหตุที่หาย................................................................................................................................

              สถานที่เกิดเหตุ.............................................................................................................................
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              วันที่เกิดเหตุ..................................................................................................................................
              ไดรับคํารองทุกขไวตามเลขคดีที่................วันที่.........เดือน.....................พ.ศ. ............ ป.จ.ว.ขอ...........
              ÃÒ¡ÒÃáÅÐตํา˹ÔÃÙ»¾Ãó·ÃѾ¶Ù¡»ÃзØÉÃŒÒÂËÃ×ÍËÒÂ
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