POLICE COMPLAINT FORM
TEST MODE TEST MODE TEST MODE NOT ACTIVE CURRENTLY Department/Agency _________________________________ IA Case Number _________________________________
Full Name Address. Include Apt number. City-State-Zip Phone Email Date of Birth
Preferred Method of Contact PHONEEMAIL ---------------------------------------- Officer(s) Subject to Allegation (Provide Whatever Info Is Known) Officer(S) Name Officer(S) Badge Number Incident Location Date / Time In the space below, describe the type of incident (traffic stop, street encounter) and any information about the alleged conduct. If you cannot fit your response below, feel free to use extra pages and attach them to this document. If you do not know the officer’s name or badge number, provide any other identifying information. ---------------------------------------- Other Information How was this reported? In-PersonBy PhoneBy LetterBy EmailOther If other, describe: Any Physical Evidence Submitted? YesNo If Yes, describe: Was incident previously reported? YesNo If Yes, describe: ---------------------------------------- To Be Completed by Officers Receiving Report Officer Receiving Complaint _________________________________ Badge No. ________ Supervisor Reviewing Complaint ______________________________ Badge No. ________ Please leave this field empty.