POLICE INTERNAL AFFAIRS

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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
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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.

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If other, describe:

Any Physical Evidence Submitted?
YesNo

If Yes, describe:

Was incident previously reported?
YesNo

If Yes, describe:

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Officer Receiving Complaint _________________________________ Badge No. ________

Supervisor Reviewing Complaint ______________________________ Badge No. ________

Please leave this field empty.