"*" indicates required fields Name of Complainant First Last Date of Birth MM slash DD slash YYYY Email PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Involved Employee*RankBadge NumberName of Involved EmployeeRankBadge NumberDate of Incident MM slash DD slash YYYY Time of Incident Hours : Minutes AM PM AM/PM Location of Incident*Nature of Complaint*Describe in your own words all details you consider necessary for the police department to investigate your complaint (use additional sheet if needed).Name of Witness First Last Witness PhoneAddress of Witness Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I understand that I will be informed of the results of the police investigation and disposition of my complaint. Please pick one: I (am) / (am not) willing to testify at any hearing relating to this complaint. I have read the above written statement and it is true and accurate to the best of my knowledge.* I am I am NOT Signature of Complainant or Parent/Guardian (if minor)*Please type your nameSignature of Witness*Please type your name Δ
