Form 4100 174 PDF Details

Form 4100 174 is used to request an extension of time to file a state income tax return. This form can be used by individuals or businesses and must be accompanied by a payment of the applicable extension fee. The extension will be granted for a period of six months, and the return must be filed with the Department of Revenue no later than six months after the initial due date. Note that this is not an automatic extension; it must be requested using Form 4100 174. For more information, please consult the instructions for Form 4100 174 or contact the Department of Revenue.

QuestionAnswer
Form NameForm 4100 174
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 4100 174, wi dnr form 4100 174, wisc dnr 4100 174, dnr 4100 174

Form Preview Example

Send Report To: Off-Highway Vehicle Program – LE/8

Off-Highway Vehicle (OHV) Incident

Department of Natural Resources

Operator Report

 

PO Box 7921

 

Madison, WI 53707-7921

Form 4100-174 (R 11/18)

Page 1 of 2

Vehicle Type:

Notice: For the purpose of this report an off-highway vehicle (OHV) means snowmobile, all-terrain vehicle (ATV), utility-terrain vehicle (UTV) or off-highway motorcycle (OHM). The operator of any ATV, UTV or snowmobile involved in a crash incident on public or private lands that results in death or injuries requiring treatment by a physician is required by sections 350.15, 23.33(7) and any OHM involved in a crash incident on public lands that results in death or injuries requiring treatment by a physician is required by section 23.335(18)

Wis. Stats., to report the incident as soon as possible to a conservation warden or a local law enforcement agency, and to submit a written report within 10 days to the Department of Natural Resources. Failure to complete this form as required may result in a forfeiture of up to $250.00. Personal information collected will be used for investigatory purposes and may be provided to requesters to the extent required by Wisconsin’s Open Records Law (ss. 19.31-19.39, Wis. Stats.).

Crash Incident Criteria

Incident Date

Day of Week

Time of Day

am

City or Township

County

State

Location of Incident:

 

 

pm

 

 

 

WI

 

 

 

Number of Vehicles in Crash

 

 

 

Private Land

Hwy. Right-of-way

Waterway

 

 

 

Injuries Requiring Medical Treatment?

Y

N

 

 

 

 

 

Public Land

Public Trail

 

Route

 

Death Related to Incident?

 

Y

N

Public Road

Private Trail

 

 

 

Disappearance of Person Indicating Injury or Death?

Y

N

Operator Information

Operator Name (First, Middle, Last)

 

Phone Number

(ext.)

Yes No N/A

 

 

 

 

Eye Protection/Face Shield?

Address

 

Date of Birth

Age

Wearing Helmet?

 

 

 

 

Seat Belt Used?

City

State ZIP Code

Gender:

 

Injured?

 

 

Male

Female

Minor–No Permanent Injury

Description of Injury

 

 

 

Major–Required Hospitalization

Completed OHV-Specific DNR Safety Training Course?

Yes - State

 

 

 

 

 

 

No - Online course?

Yes

No

 

Unknown

 

 

Vehicle Information (Vehicle A)

Operator Experience:

0 - 100 Hours

Over 100 Hours

OHV Type:

Snowmobile

ATV

UTV

OHM

Other

 

 

 

 

OHV is:

Rented

Borrowed

Owned

 

 

 

 

 

 

Owner Name (First, Middle, Last)

Same as Operator

 

 

Phone Number

(ext.)

Address

 

 

 

 

City

 

 

 

State ZIP Code

Make

 

Model

 

 

Year

Decal Number

 

Exp. Date

State

Vehicle ID Number

Engine Size

Studs/Chains?

Estimated Speed

Designed to Seat How Many?

 

 

 

 

CC

Yes

No

 

MPH

 

 

Passengers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Passenger Name (First, Middle, Last)

 

 

Phone Number

(ext.)

 

Yes No N/A

 

 

 

 

 

 

 

 

Eye Protection/Face Shield?

 

Address

 

 

 

 

Date of Birth

Age

Wearing Helmet?

 

 

 

 

 

 

 

 

 

Seat Belt Used?

 

City

 

 

State

ZIP Code

Gender:

 

Injured?

 

 

 

 

 

 

 

Male

Female

 

Minor–No Permanent Injury

Description of Injury

 

 

 

 

 

 

 

Major–Required Hospitalization

 

 

 

 

 

 

 

 

 

Fatal

 

OHV Incident – Operator Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 4100-174 (R 11/18)

 

Page 2 of 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Party Involved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (First, Middle, Last)

 

 

 

 

 

 

 

 

Phone Number

 

 

(ext.)

Describe Involvement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

Age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injured?

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

 

ZIP Code

 

 

Gender:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

Female

 

 

 

Minor–No Permanent Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Major–Required Hospitalization

Description of Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fatal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Vehicle Involved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Type:

Snowmobile

ATV

 

 

UTV

OHM

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Decal Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Operator Name (First, Middle, Last)

 

 

 

 

 

 

 

Date of Birth

 

Age

 

 

Gender:

 

 

Phone Number

(ext.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witnesses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First, MI, Last Name

 

 

 

 

 

 

Address

 

 

 

 

 

 

Birthdate

 

 

Phone Number

 

Sex

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

Type and Cause of Accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Environment

 

 

 

 

 

 

 

 

 

 

 

Type of Incident: (select all that apply)

 

 

Activity at Time of Incident:

 

 

 

Weather:

 

 

 

 

Visibility:

 

 

 

Fell/ejected from OHV

 

 

 

 

Recreational

 

 

 

 

 

 

 

 

 

Foggy - Mist

 

 

 

 

Day

 

 

 

Night

 

Collision with fixed object

 

 

 

 

Agricultural

 

 

 

 

 

 

 

 

 

Raining

 

 

 

 

 

 

Good

 

 

 

Collision with another OHV

 

 

 

 

Sanctioned Race (ATV/UTV only)

 

 

 

 

Snowing

 

 

 

 

 

 

Fair

 

 

 

Collision with moving motor vehicle

 

 

Construction

 

 

 

 

 

 

 

 

 

Clear

 

 

 

 

 

 

Poor

 

 

 

 

 

Hunting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collision with parked motor vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

Temperature

 

 

 

 

Road Condition:

 

 

 

Broke through ice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

°F

 

 

Dry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What in Your Opinion Contributed to

 

 

 

 

 

 

 

 

 

 

 

Driven into open water

 

 

the Incident?

 

 

 

 

 

 

 

 

Trail Condition:

 

 

 

 

 

 

Wet

 

 

 

OHV rolled over/Tip over

 

 

 

 

Drinking or Drugs

 

 

 

 

 

 

Icy

 

 

 

 

 

 

Snow Covered

 

 

 

 

 

 

Vehicle speed

 

 

 

 

 

 

 

 

 

Smooth

 

 

 

 

 

 

 

 

Struck fence or cable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Equipment failure

 

 

 

 

 

 

 

 

 

 

 

 

Icy

 

 

 

 

 

 

 

 

 

 

 

 

 

Rough

 

 

 

 

 

 

 

 

 

Injured by contact with part of OHV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Failure to yield

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gravel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Muddy

 

 

 

 

 

 

 

 

 

Pedestrian struck by OHV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inexperience

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dry

 

 

 

 

 

 

Paved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Being pulled by OHV

 

 

 

 

Trail conditions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

Other

 

 

 

Other

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe What Happened (Sequence of events leading up to the incident)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please double check your report for accuracy. Pursuant to s. 350.15(4), Wis. Stats., and NR64.10, Wis. Admin. Code, this report may

not be used as evidence in any trial.

 

 

Printed Name of Operator

Signature of Operator

Date Signed (MM/DD/YYYY)

Incident reported to (name of Warden or Law Enforcement Agency):

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Pay attention when completing this pdf. Make sure that all required areas are completed properly.

1. The 4100 174 report wisconsin needs specific details to be typed in. Be sure the next blank fields are complete:

Writing section 1 of wi dnr atv accident report

2. Once your current task is complete, take the next step – fill out all of these fields - City, Description of Injury, State ZIP Code, Gender Male, Female, Eye ProtectionFace Shield Wearing, MinorNo Permanent Injury, Completed OHVSpecific DNR Safety, State Online course, Yes No Unknown, Yes, Operator Experience, Hours Over Hours, Vehicle Information Vehicle A OHV, and Snowmobile with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

wi dnr atv accident report conclusion process outlined (step 2)

3. This 3rd section should also be fairly easy, City, Description of Injury, State ZIP Code, Gender Male, Female, Eye ProtectionFace Shield Wearing, and MinorNo Permanent Injury - all of these empty fields is required to be completed here.

Filling out segment 3 in wi dnr atv accident report

4. Completing Phone Number, ext, Describe Involvement, Date of Birth, Age, State ZIP Code, Gender Male, Female, Injured, Yes No, MinorNo Permanent Injury, ATV, UTV, OHM, and Other is key in this part - always be patient and fill in each blank!

Part no. 4 for submitting wi dnr atv accident report

5. While you get close to the last sections of the document, there are several more requirements that must be fulfilled. In particular, M F, M F, Night, Type and Cause of Accident Type, Fellejected from OHV Collision, Activity at Time of Incident, Recreational Agricultural, What in Your Opinion Contributed, Drinking or Drugs Vehicle speed, Describe What Happened Sequence of, Environment Weather, Foggy Mist Raining Snowing Clear, Visibility Day, Good Fair Poor, and Temperature must be filled in.

Writing segment 5 of wi dnr atv accident report

Always be extremely attentive when filling out M F and Type and Cause of Accident Type, as this is where most users make mistakes.

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