Officer Memorial Submission Form

Please complete this form to submit an officer’s name for possible inclusion on the Wisconsin Law Enforcement Memorial.  Wisconsin Law Enforcement Memorial, Inc., will consider line of duty deaths for the annual ceremony to those that occurred prior to December 31 of the previous year, provided Wisconsin Law Enforcement Memorial, Inc., has received complete submissions no later than Feb. 1st of the current year.  Wisconsin Law Enforcement Memorial, Inc., may review and approve names at any scheduled meeting held throughout the year.

Supporting documentation is required for all submissions.  Supporting documentation includes but is not limited to the following; death certificate, agency incident report, criminal complaint, medical examiner's report, newspaper articles, etc.  Supporting documentation can be attached by clicking the "Choose Files" button near the bottom of this submission form or mail the documentation to the Wisconsin Law Enforcement Memorial, Inc. P.O. Box 2733, Madison, WI 53701-2733.  If you have any questions submit an email to or call 608-846-9854.

Officer Information
Date of Death
Date of Incident (if different)
Agency Information
Survivor's Information

In an attachment or the area below, please provide the name, address, and phone of the officer's spouse, children, parents, and siblings. Please indicate if the children are minors or adults. If you are unable to provide survivor information are you willing to relay information about WLEM and Memorial events to the family? (please check below)

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