Complaint Form

Name(required)

Date of Birth

Race

Gender

Address

City

State

Zip Code

Home Phone(required)

Work Phone

Cell Phone

Email(required)

Location or Address of Occurrence

Date of Occurrence(required)

Time of Occurrence(required)

Officer(s) Involved in the Occurrence – Name, Rank, Division and Assignment(required)

Officer's Shift(required)

Witness 1 Name

Witness 1 Address

Witness 1 Relationship to Complainant

Witness 1 Phone Number

Witness 2 Name

Witness 2 Address

Witness 2 Relationship to Complainant

Witness 2 Phone Number

Provide a full description of the circumstances that prompted your complaint(required)