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2. Select One

   1. Commendation

   1. Complaint
4. Last Name
5. First Name
6. Middle Name
8. Address
10. City
11. State
12. Zip Code
14. Age
15. Race
16. Sex
20. Citizen Information
22. Cell Phone #
23. Home Phone #
24. Work Phone #
25. Email address
27. Location or Address of Occurrence*
28. Date of Occurrence*
    Date of Occurrence
29. Time of Occurrence*
    Time of Occurrence
31. Officer Involved in the Occurrence—Name, Rank
32. Officer’s Shift
34. Officer Involved in the Occurrence—Name, Rank
35. Officer’s Shift
37. Officer Involved in the Occurrence—Name, Rank
38. Officer’s Shift
42. Witness Information
44. Witness Full Name & Address
45. Relationship to Citizen
46. Witness-Phone Number
48. Witness Full Name & Address
49. Relationship to Citizen
50. Witness-Phone Number
52. Details of the Incident: Provide a full description of the circumstances that prompted your complaint/commendation.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field