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2. CITIZEN COMPLAINT FORM
   Please fill out the form below as accurately and completely as possible. You do not have to leave identifying information such as your name and phone number, but if you do not leave that information we will not be able to follow up with you if we have additional questions once an investigation is started.
4. First Name
5. Middle Name
6. Last Name
7. Suffix
   -- Select One --Jr.Sr.IIIIIIV
9. Gender

   1. Male
   2. Female
10. Race

    1. Caucasian
    2. African American
    3. Asian & Pacific Islander
    4. American Indian or Inuit
11. Ethnicity

    1. Hispanic or Latino
    2. Not Hispanic or Latino
13. Date of Birth
    MM/DD/YYYY
14. Primary Phone Number
    999-999-9999
15. Secondary Phone Number
    999-999-9999
17. Address1
19. Address2
21. City
22. State
23. Zip
25. E-mail address (primary)
26. E-mail address (secondary)
28. Employer
29. Work address
30. Work phone number
34. Date & Time of Incident*
    Date & Time of Incident

    Date & Time of Incident
    Approximate date and time if exact time is unknown
35. Location of Incident*
    Address or approximate location
37. Type of Incident*
    -- Select One --Traffic stopTraffic crashArrestDomestic (dispute or assault)911 call/Call for ServiceSuspicious person or conditionAll other calls
38. Number of Officers*
    -- Select One --1234 or more
39. Enforcement Action*
    -- Select One --NoneVerbal WarningWritten WarningCitation or TicketPhysical Arrest
41. Nature of Complaint*

    1. Rude conduct toward me or a third party
    2. Use of foul or inappropriate language
    3. Unprofessional conduct toward me or a third party
    4. Vehicle operation not in compliance with traffic laws
    5. I believe the situation I was involved in was handled poorly or unfairly
    6. Other, please see narrative

    Please select the option or options that best describes the nature of your complaint. You may select more than one option.
43. Name of Officer
44. Physical description
46. Name of Officer
47. Physical description
49. Name of Officer
50. Physical description
52. Name and Contact Information of any witnesses
    Please fill out the name, approximate age and phone number of any witness to the events.
56. Description of incident*
    As clearly and concisely as possible, please describe the incident in question.
58. Signature of Complainant*
    Signature or your typed name will be sufficient for this block
59. Date and Time
    Date and Time

    Date and Time
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

* indicates a required field