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Complaint Form

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Date and Time of Report*
Date and Time of Report
Date and Time of Report
Date and Time of Incident*
Date and Time of Incident
Date and Time of Incident
First Name*
Last Name*
Age*
Date of Birth*
Date of Birth
Race*
Other
Home Address
Street Address*
Address Line 2
City*
State*
ZIP Code*
Phone*
Business Address
Street Address
Address Line 2
City
State
ZIP Code
Phone
Driver's License Number*
State*
Were you charged with an offence in this incident?*
1. No
2. Yes
If yes what charges where filed?
Name and rank of officer involved (if known), list details of the event.
What type of complaint are you filling? Check all that apply.*
1. Excessive Force
2. Inappropriate Conduct
3. Other
4. Racial Offense
5. Rudeness
6. Service Complaint
Other