2. 
   

   COMPLAINANT CONTACT FORM

4. Today's Date:*
   Today's Date:

5. To initiate a complaint, please complete this form. A police official will contact you with additional questions and to let you know the outcome of the investigation.

9. COMPLAINANT INFORMATION

11. First Name*
12. Last Name*
13. Date of Birth*
    Date of Birth
14. Age*
16. Sex*

    1. Male
    2. Female
17. Address*
18. Apartment #
20. City*
21. State*
22. Zip Code*
24. Phone Number
25. Home Number
27. Work Number
28. Email Address

32. SUBJECT(S) & WITNESS(ES)

34. Location

    Give address, if known

36. Subject Officer(s)

38. Date*
    Date

    Date
39. Police Report/Citation #
41. 1. Name*
42. Badge #
43. Description
44. Sex*

    1. Male
    2. Female
46. 2. Name
47. Badge #
48. Description
49. Sex

    1. Male
    2. Female
51. 3. Name
52. Badge #
53. Description
54. Sex

    1. Male
    2. Female
56. 
    

    Officer Witness(es)

58. 1. Name
59. Badge #
60. Description
61. Sex

    1. Male
    2. Female
63. 2. Name
64. Badge #
65. Description
66. Sex

    1. Male
    2. Female

68. Civilian Witness(es)

70. 1. First Name
71. Last Name
73. Date of Birth
    Date of Birth
74. Age
75. Race
76. Phone Number
78. Address
79. City
80. State
82. Zip Code
84. 2. First Name
85. Last Name
87. Date of Birth
    Date of Birth
88. Age
89. Race
90. Phone Number
92. Address
93. City
94. State
96. Zip Code

100. INCIDENT

102. Enter the Details of your Complaint
106. Electronic Signature Agreement

     By selecting the "I agree" checkbox below, you confirm and acknowledge that all the information provided is true to the best of your knowledge. Furthermore, by signing in this alternative manner, you authorize your electronic signature to carry the same legal validity and binding effect as a handwritten signature. It is important to note that you might be required to provide a traditional signature at a later date.

     1. I agree.
108. Electronic Signature
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field