1. Reporting individual
• Full name: ……………………………………………………..
• Citizen ID number: …………………………..
• Primary residence address: ………………………………….
• Relationship to the reported person:
☐ None
☐ Neighbor
☐ Colleague
☐ Family member
☐ Other: …………………………………………………………

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2. Person or group being reported
• Name(s): ……………………………………………..
• Description: ……………………………………………..
• Location observed: …………………………………………

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3. Nature of the observed behavior
(Check all that apply)
☐ Critical remarks regarding the Big Nation
☐ Questioning of Proconsular authority
☐ Excessive attachment to local traditions
☐ Informal gatherings of an ambiguous nature
☐ Distribution of unauthorized books
☐ Communication in a prohibited language
☐ Other behavior deemed concerning: ……………………………………..

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4. Detailed description of the facts
Please describe the observed facts clearly and objectively.
……………………………………………………………………..
……………………………………………………………………..
……………………………………………………………………..
……………………………………………………………………..

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5. Frequency and duration
• Date(s) of the events: ………………………………….
• Estimated frequency:
☐ Isolated
☐ Repeated
☐ Regular
☐ Persistent

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6. Declaration
I certify that the information provided is accurate to the best of my own perception of the facts and my assessment at the time.

Date: ………………………………….
Signature: ………………………………

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Important notice
Every report contributes to the maintenance of stability, security, and collective harmony.
Deliberate omissions, false statements, or other distortions of the facts may not be tolerated, depending on the individual or individuals concerned.
The Big Nation thanks vigilant citizens who actively contribute to the preservation of order.