Citizen’s Complaint Form Against Police

Citizen’s Complaint Form Against Police
Questions marked by * are required.
1.	Last Name: *
2.	First Name: *
3.	Middle Name:
4.	Date of Birth:
5.	Race/Ethnicity: *
6.	Nationality:
7.	Address: *
8.	State: *
9.	Zip: *
10.	Cell Phone Number:
11.	Other Number:
12.	Email: *
13.	Law Enforcement Agency: *
14.	Officer’s Name: *
15.	Badge Number: *
16.	Officer’s Vehicle Number: *
17.	Date of Incident: *
18.	Time of Incident: *
19.	Time of Day: * AM PM
20.	Location of incident: *
21.	Please describe in detail what happened: *
22.	Electronic Signature: *
23.	Date: *