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2. This document is confidential in nature and the information is not subject to public disclosure.
   I understand this statement of complaint is......
4. Name of complainant*
6. Filed on behalf of
8. Street Address*
10. City*
11. State
12. Zip Code
14. Home Phone
15. Work Phone
16. Cell Phone
18. Best time of day to contact you
20. Date and time of occurence*
    Date and time of occurence

    Date and time of occurence
22. Location of occurrence
24. Name of member(s) complaint is being filed against...........
26. Rank
27. Name
29. ID#
30. Vehicle
32. List any witnesses
    Name(s), Address(s), Telephone number(s) of other providing information, etc...
34. Type of complaint
36. Type of complaint
    -- Select One --DiscourtesyFalse ArrestExcessive Force
38. Details of complaint
40. Acknowledgment*

    I agree that this signature is binding as my legal signature and that all information provided is correct.......

    1. I Agree
42. Acknowledgment*
    By putting your initials in this field you agree that this signature is binding as your legal signature and that all information provided is correct.......
44. Signature of Complainant*
45. Date and Time*
    Date and Time

    Date and Time
47. Internal Use Only
    Do not fill out this area below.
49. Signature of Person Receiving Complaint
50. Date and Time received
    Date and Time received

    Date and Time received
52. Division Commander
53. Date
    Date
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field